INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 25, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Avenues Recovery Center of Lake Ariel 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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705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on client interviews and the facility's Tobacco policy, the facility failed to limit smoking to designated smoking areas.
Per the Tobacco policy, smoking of tobacco products is prohibited within all buildings. Avenues shall designate smoking areas outside.
During client interviews, %75 of those questioned reported vaping occurs inside the facility.
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Plan of Correction
The Operations Manager is responsible for ensuring that staff continue to enforce the tobacco policy which includes smoking and vaping in designated outdoor areas only. All staff are oriented into Avenues policies upon hire which includes the tobacco policy and staff were re-trained on this policy on 3/25. Staff will report to the patient's primary therapist any reports of rule violation to be addressed as part of the treatment plan with the treatment team. |
709.63(a)(3) LICENSURE Progress notes
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(3) Progress notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include progress notes, in one of five records reviewed.
Client # 2 was admitted November 19, 2024, and discharge November 26, 2024. The client record did not contain documentation of Detox Progress Notes for November 21, 2024, and November 22, 2024.
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Plan of Correction
As part of the patient's treatment plan, assessment of the progress of the patient was to occur daily while in the detox level of care. The medical team is responsible for carrying out the treatment plan in the detox level of care with oversight and auditing completed by the chart auditor to ensure the charting is completed in the patient's record. The chart auditor is auditing all current patients to ensure that daily assessments, if in the treatment plan, has been documented and will continue to do so on a weekly basis. |
709.63(a)(4) LICENSURE Medication records
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(4) Medication records.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include medication records, in one of five records reviewed.
Client # 2 was admitted November 19, 2024, and discharge November 26, 2024. Per the Nursing Assessment, Medication Destruction Record, and the Client Discharge Sign Off Sheet, all medications brought in by the client were not documented as being destroyed, nor returned to the client.
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Plan of Correction
The nurse manager, together with the corporate Director of Medical Development are responsible for ensuring the medical policies, including medication records in the patient chart, are documented. The medical team was under the assumption that narcotics were only to be logged in the pharmacy provided forms in the medication room for both patient specific medication and stock medication. The Director of Medical Development has retrained the medical staff on the importance of ensuring this also gets documented in the patient's medical record for patient specific medication. The nurse manager is auditing all logs to ensure that any patient specific medication's status (stored, returned, destroyed, continued, etc) is documented in the patient's record. |