INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Avenues Recovery Center of Bucks, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training, during the facility's January 1, 2024 through December 31, 2024 training year, in three of five applicable personnel records reviewed.
Employee # 3 was hired as a counselor on May 23, 2017. The personnel record documented 13.5 hours of training received during the training year reviewed.
Employee # 4 was hired as a counselor on August 13, 2018. The personnel record documented 24.25 hours of training received during the training year reviewed.
Employee # 5 was hired as a counselor on September 20, 2021. The personnel record documented 13.5 hours of training received during the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager is responsible for ensuring that counseling staff meet the 25 clock hour training requirement. Employee #3 and #5 were issued 11.5 hours of training and Employee #4 was issued 1 hour of additional training to satisfy the 2024 training year. All three employees will be responsible for completing 25 hours of training in the 2025 training year and each year forward. The Operations Manager continues to monitor the completion of these trainings and employees are on target to complete the missing training hours by 2/17/2025. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the January 2024 through December 2024 fire drill logs, the facility failed to document on their written fire drill log the time of the fire drill.
The fire drill log completed for the August 27, 2024 fir drill did not include the time the drill was conducted.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager is responsible for conducting fire drills on a monthly schedule and to satisfy all reporting requirements, including the time the drill was conducted. The Executive Director is responsible for ensuring that the Operations Manager inputs all relevant information in to the fire drill logs. All fire drill logs to date have been audited for compliance and all other logs are in compliance with all information entered. |