INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13, 2020 and February 18, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
The facility failed to ensure that the client-used refrigerator, located in the kitchen area, was within the required temperature range to keep cold food at or below 40 degrees Fahrenheit. Based on a review of the facility-provided refrigerator temperature logbook for the time period of March 2019 through January 2020, temperatures were above 40 degrees Fahrenheit 3 days in March 2019, 12 days in April 2019, 8 days in May 2019, 14 days in June 2019, 18 days in July 2019, 19 days in October 2019, 18 days in November 2019, 18 days in December 2019 and 21 days in January 2020. There was no additional information provided on the log to explain the higher temperature readings and no action was taken to resolve the issues.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Physical Plant designee (Admissions Coordinator) that is responsible for checking the refrigerator temperature, will ensure to take actions necessary to adjust the temperature if it reads above 40 degrees and will accurately mark the refrigerator log sheet. This issue was corrected on site. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in twelve of fourteen client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on September 19, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to the funding source, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates.
Client # 2 was admitted to the partial hospitalization activity on September 6, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to the funding source, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates.
Client # 3 was admitted to the partial hospitalization activity on November 22, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to the funding source, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates.
Client # 4 was admitted to the partial hospitalization activity on May 2, 2019 and was discharged on May 31, 2019. The record contained a consent to release information form to the funding source, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates.
Client # 5 was admitted to the partial hospitalization activity on February 21, 2019 and was discharged on June 19, 2019. The record contained a consent to release information form to the funding source, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates.
Client # 6 was admitted to the partial hospitalization activity on June 12, 2019 and was discharged on January 27, 2020. The record contained consent to release information forms to the funding source and a probation officer, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates, psychosocial assessment, psychiatric history and assessment, results of physical exam, medical history/current status, biopsychosocial assessment, lab results, employment information, legal status, family information, aftercare recommendations, discharge planning, discharge summary and financial information.
Client # 8 was admitted to the outpatient activity on April 23, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to the funding source, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates.
Client # 9 was admitted to the outpatient activity on February 18, 2019 and was discharged on March 12, 2019. The record contained a consent to release information form to the funding source, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates.
Client # 10 was admitted to the outpatient activity on June 11, 2019 and was discharged on December 2, 2019. The record contained a consent to release information form to the funding source, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates.
Client # 11 was admitted to the outpatient activity on October 3, 2019 and was still active at the time of the inspection. The record contained consent to release information forms to the funding source and a judge, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates, psychosocial assessment, psychiatric history and assessment, results of physical exam, medical history/current status, biopsychosocial assessment, lab results, employment information, legal status, family information, aftercare recommendations, discharge planning, discharge summary and financial information.
Client # 12 was admitted to the outpatient activity on January 27, 2020 and was still active at the time of the inspection. The record contained consent to release information forms to the funding source and a judge, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates, psychosocial assessment, psychiatric history and assessment, results of physical exam, medical history/current status, biopsychosocial assessment, lab results, employment information, legal status, family information, aftercare recommendations, discharge planning, discharge summary and financial information.
Client # 14 was admitted to the outpatient activity on December 2, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to the funding source, signed and dated by the client at intake, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans and treatment plan updates.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The release of information form has been updated by the EMR administrator to accurately reflect the five authorized pieces of information noted in 255.5 to release information to insurance companies and legal parties. The old ROI has been disabled from the EMR, and therefore, will not be an issue moving forward.
All active clients have signed a new ROI in the EMR with the Admissions Coordinator that meet the 255.5 regulations. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
The facility failed to document the dated signature of the client on a release of information form in one of fourteen client records reviewed.
Client #14 was admitted to the outpatient activity on December 2, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to a school that was not signed or dated by the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The QA Specialist is responsible for ensuring that all releases are signed and dated by the client and witness in a timely manner during his review of charts on a regular basis.
All active clients have signed a new ROI in the EMR with the Admissions Coordinator. |
709.28 (c) (5) 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. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
The facility failed to document the dated signature of the witness on release of information forms in two of fourteen client records reviewed.
Client # 11 was admitted to the outpatient activity on October 31, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to a judge that was not signed or dated by the witness.
Client #14 was admitted to the outpatient activity on December 2, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to a school that was not signed or dated by the witness.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The QA Specialist is responsible for ensuring that all releases are signed and dated by the client and witness in a timely manner during his review of charts on a regular basis.
All active clients have signed new ROIs in the EMR with the Admissions Coordinator. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
The facility failed to document that a copy of release of information forms were offered to the client in thirteen of fourteen client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on September 19, 2019 and was still active at the time of the inspection. The record contained consent to release information forms to family members, an attorney, a significant other, and another treatment facility, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 2 was admitted to the partial hospitalization activity on September 6, 2019 and was still active at the time of the inspection. The record contained consent to release information forms to family members, another individual, and another treatment facility, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 4 was admitted to the partial hospitalization activity on May 2, 2019 and was discharged on May 31, 2019. The record contained consent to release information forms to family members, another individual, and another treatment facility, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 5 was admitted to the partial hospitalization activity on February 21, 2019 and was discharged on June 19, 2019. The record contained consent to release information forms to family members, another individual, and another treatment facility, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 6 was admitted to the partial hospitalization activity on June 12, 2019 and was discharged on January 27, 2020. The record contained consent to release information forms to a physician, an attorney, a family member, and another treatment facility, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 7 was admitted to the partial hospitalization activity on January 18, 2019 and was discharged on April 19, 2019. The record contained consent to release information forms to family members and another treatment facility, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 8 was admitted to the outpatient activity on April 23, 2019 and was still active at the time of the inspection. The record contained consent to release information forms to family members and another treatment facility, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 9 was admitted to the outpatient activity on February 18, 2019 and was discharged on March 12, 2019. The record contained consent to release information forms to family members, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 10 was admitted to the outpatient activity on June 11, 2019 and was discharged on December 2, 2019. The record contained consent to release information forms to family members and another individual, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 11 was admitted to the outpatient activity on October 3, 2019 and was still active at the time of the inspection. The record contained consent to release information forms to family members, another treatment facility, and a judge, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 12 was admitted to the outpatient activity on January 27, 2020 and was still active at the time of the inspection. The record contained consent to release information forms to a physician, an attorney, a family member, and another treatment facility, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 13 was admitted to the outpatient activity on April 19, 2019 and was still active at the time of the inspection. The record contained consent to release information forms to family members and another treatment facility, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
Client # 14 was admitted to the outpatient activity on December 2, 2019 and was still active at the time of the inspection. The record contained consent to release information forms to a physician, another individual, another treatment facility and family members, signed and dated by the client at intake, that failed to document if the client was offered a copy of the release of information forms.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The EMR administrator had updated the ROI in the system in the fall of 2019 to include that a client was offered a copy of the release and will not be an issue moving forward.
All active clients have signed new ROIs in the EMR with the Admissions Coordinator. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
The facility failed to file a written unusual incident report with the Department within 3 business days following the facility being notified of an off-site death of a recently discharged client.
Per the facility's written policy, the Department is to be notified of the death of a client when the facility is made aware within 72 hours of the client's discharge from the facility. Client # 9 was admitted to the outpatient activity on February 18, 2019 and was discharged on March 12, 2019. The facility was notified of the client's death on March 13, 2019.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Compliance is responsible for ensuring that all staff members follow the facility's policies and procedures and a staff meeting was held to review. All unusual incidents that require notification to DDAP will occur in a timely manner as appropriate to the regulations and the policies set forth by the facility. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
The facility failed to properly document the type of services the client was to receive on the comprehensive treatment and rehabilitation plan in three of seven client records reviewed. Additionally, the facility failed to document supportive services on the comprehensive treatment and rehabilitation plan in one of seven client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on September 19, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on September 27, 2019. Supportive services was not included on the treatment plan.
Client # 3 was admitted to the partial hospitalization activity on November 22, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on November 27, 2019. The type of treatment was not included on the treatment plan.
Client # 4 was admitted to the partial hospitalization activity on May 2, 2019 and was discharged on May 31, 2019. The comprehensive treatment plan was completed on May 6, 2019. The type of treatment was not included on the treatment plan.
Client # 7 was admitted to the partial hospitalization activity on January 18, 2019 and was discharged on April 19, 2019. The comprehensive treatment plan was completed on January 29, 2019. The type of treatment was not included on the treatment plan.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director held a meeting with all staff to ensure that the type of services the client receives and the documentation of supportive services is included on the comprehensive treatment plan. The QA specialist is responsible for ensuring this is being recorded in the treatment plan on a regular basis. |
709.83(a)(4) LICENSURE Client records
709.83. 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) Case consultation notes.
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Observations
The facility failed to provide case consultation notes in the client's complete record in three of seven client records.
Client # 1 was admitted to the partial hospitalization activity on September 19, 2019 and was still active at the time of the inspection.
Client # 6 was admitted to the partial hospitalization activity on June 12, 2019 and was discharged on January 27, 2020.
Client # 7 was admitted to the partial hospitalization activity on January 18, 2019 and was discharged on April 19, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director held a meeting with staff to provide them with a process for case consults in the patients record. Due to the extended care program, the facility has implemented that case consults will be done every 30 days on patients admitted to the facility and will be recorded in the client record. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
The facility failed to properly document the type and frequency of services the client was to receive on the comprehensive treatment and rehabilitation plan in six of seven client records reviewed.
Client # 8 was admitted to the outpatient activity on April 23, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on April 25, 2019. The type of treatment was not included on the treatment plan.
Client # 9 was admitted to the outpatient activity on February 18, 2019 and was discharged on March 12, 2019. The comprehensive treatment plan was completed on February 26, 2019. The type of treatment was not included on the treatment plan
Client # 10 was admitted to the outpatient activity on June 11, 2019 and was discharged on December 2, 2019. The comprehensive treatment plan was completed on June 17, 2019. The type of treatment was not included on the treatment plan
Client # 11 was admitted to the outpatient activity on October 3, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on October 9, 2019. The type of treatment was not included on the treatment plan
Client # 13 was admitted to the outpatient activity on April 19, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on April 29, 2019. The type of treatment was not included on the treatment plan
Client # 14 was admitted to the outpatient activity on December 2, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on December 20, 2019. The type of treatment was not included on the treatment plan
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director held a meeting with all staff to ensure that the type and frequency of services the client receives is included on the comprehensive treatment plan. The QA specialist is responsible for ensuring this is being recorded in the treatment plan on a regular basis. |
709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
The facility failed to provide case consultation notes in the client's complete record in three of seven client records.
Client # 10 was admitted to the outpatient activity on June 11, 2019 and was discharged on December 2, 2019.
Client # 11 was admitted to the outpatient activity on October 3, 2019 and was still active at the time of the inspection.
Client # 13 was admitted to the outpatient activity on April 19, 2019 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director held a meeting with staff to provide them with a process for case consults in the patients record. Due to the extended care program, the facility has implemented that case consults will be done every 30 days on patients admitted to the facility and will be recorded in the client record. |