INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted August 25-27, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site investigation, Avenues Recovery Medical Center at Valley Forge, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.12(a)(4)(i) LICENSURE Inpat. Hosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(4) Inpatient hospital treatment and rehabilitation (general, psychiatric or speciality hospital).
(i) Projects serving adult clients shall have one FTE counselor for every seven clients.
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Observations
Based on a review of the Staffing Requirements Summary Report for June 5, 2026 and June 18, 2026, the facility failed to comply with the counselor/client ratios. On June 5 and 11, 2026 the ratio was 1:11 instead of 1:7.
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Plan of Correction
Since the time of the identified deficiency, the facility has hired additional counseling staff and has restored compliance with the required 1:7 counselor-to-client ratio. Staffing levels will be monitored by the Clinical Director or a designee on an ongoing basis, and the Clinical Director is ultimately responsible for this plan of correction. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of patient charts and other administrative documentation, it was determined that the facility failed to obtain an informed consent from a patient for the disclosure of his information. Email correspondence showed that on February 4, 2026, a facility employee emailed a patient name with treatment information to an external agency employee without a signed consent.
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Plan of Correction
The Director of Case Management or a designee will ensure that all available Case Management staff are educated on confidentiality and the informed consent process by October 16, 2026.
The Director of Case Management or a designee will audit 5 random charts per week for compliance with the informed consent process. Audits will continue until compliance is maintained for 3 consecutive months.
Data from these audits will be reported to the QAPI committee monthly for 3 months.
The Director of Case Management is ultimately responsible for this plan of correction.
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710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of patient charts and facility policies, the facility failed to keep patient records confidential and to follow its Confidentiality Policy.On June 19, 2026, confidential patient paperwork was included in another patient's belongings upon discharge.
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Plan of Correction
The Director of Case Management or a designee will ensure that all available Case Management staff are educated on the Privacy and Confidentiality Policy by October 16, 2026.
The Director of Case Management or a designee will audit 5 random charts per week for compliance with the Confidentiality Policy. Audits will continue until compliance is maintained for 3 consecutive months.
Data from these audits will be reported to the QAPI committee monthly for 3 months.
The Director of Case Management is ultimately responsible for this plan of correction.
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