This report is a result of an off-site complaint investigation conducted on July 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the complaint investigation, the allegations against Avenues Recovery Center of Lake Ariel, LLC were partially substantiated. Avenues Recovery Center of Lake Ariel, 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 complaint investigation:
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Plan of Correction
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Observations
Based on a review of the facility-submitted daily census for the months of January 2021 through June 2021 and a discussion with facility staff; the facility failed to notify the Department of a change in authorized maximum capacity.
The facility currently has a maximum licensed capacity of 26 for their Inpatient Non-Hospital activity. However, the facility had daily client capacities above the licensed 26 on the following days:
- February 2, 2021 through February 10, 2021; February 12, 2021 through February 18
- May 21, 2021, through May 24, 2021; May 26, 2021 through May 31, 2021
- June 1, 2021 through June 7, 2021.
This finding was discussed with facility staff during the investigation.
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Plan of Correction
The Project Director has submitted a request for a flex bed waiver on 7/2/2021 to the licensure division. While we await approval from DDAP, the Project Director is responsible for ensuring that we do not go above the capacity in our Inpatient Non-Hospital activities by daily monitoring of all patients and their respective levels of care. If the need arises, we will transfer patients to other licensed programs that's agreed upon with the patient to not effect their continuum of care. |