INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 10, 2022 through August 11, 2022 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 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 inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility ' s Staffing Requirements Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee #8 was hired as a BHT on February 6, 2020 and was due to have the HIV/AIDS training no later than February 6, 2022. The HIV/AIDS training was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Administrator is responsible for ensuring that all counselors receive at minimum 6 hours of HIV/ADS with a DDAP approved curriculum within one year of hire for counselors and within 2 years of hire for all other staff. This employee continues to struggle with signing up through the training website, therefore, the Director of Clinical Development and Medical Director will be creating a 6 hour training course to ensure that all employees, including this individual, obtain the required hours and training on the DDAP required curriculum. All other employees are currently compliant with this regulation. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual and client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of two applicable client records reviewed.
Per the policy and procedure manual, the program will contact the client's emergency contact when the client leaves against medical advice immediately and within 12 hours of leaving the facility.
Client #7 was admitted on April 15, 2022 and was discharged against medical advice on April 23, 2022. There was no attempted emergency contact notification documented in the record at the time of the inspection.
Client #11 was admitted on May 9, 2022 and was discharged against medical advice on June 6, 2022. There was documentation that the emergency contact was notified of the client leaving the facility against medical advice; however, the contact was made on July 19, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director is responsible for ensuring that all patients who discharge against medical advice have documentation in their medical record that proves that emergency contact(s) were called within 12 hours of their departure. These patients now have documentation entered in their medical record that accurately reflect when the contact was made; which was within 12 hours per ongoing facility communication at the time of their discharge. |
709.83(a)(11) 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:
(11) Follow-up information.
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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 follow-up information, in one of three applicable client records reviewed.
Client #15 was admitted on October 11, 2021 and was discharged on November 2, 2021. There was no documentation of follow-up information in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director is responsible for ensuring that all follow up calls are made and documented. This was reviewed with the responsible staff at the conclusion of the inspection. Follow up documentation was not provided at time of inspection, however, was found after the departure of the inspector in our CRM software and future correspondence will be readily accessible at the time of next inspection. |
709.62(c)(1) LICENSURE Disclosure documentation
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document the disclosure to the client of the criteria for admission, treatment, completion, and discharge, during the detox intake process, in three of seven client records reviewed.
Client #1 was admitted on August 5, 2022 and was still active at the time of the inspection.
Client #2 was admitted on August 6, 2022 and was still active at the time of the inspection.
Client #4 was admitted on August 2, 2022 and was discharged on August 9, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director is responsible for ensuring that all documentation at time of admission/intake is completed and signed by the patient and staff witness, as appropriate. This includes the orientation process for criteria for admission, treatment, completion, and discharge while in detox.
These clients have signed the appropriate paperwork acknowledging the above at the time of inspection.
The facility has changed the after hour admission process to ensure that this does not get missed in the future.
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709.62(c)(2)(i) LICENSURE Orientation Proj policies
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(i) Project policies, which include the following:
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the project's policies, during the detox intake process, in three of seven client records reviewed.
Client #1 was admitted on August 5, 2022 and was still active at the time of the inspection.
Client #2 was admitted on August 6, 2022 and was still active at the time of the inspection.
Client #4 was admitted on August 2, 2022 and was discharged on August 9, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director is responsible for ensuring that all documentation at time of admission/intake is completed and signed by the patient and staff witness, as appropriate. This includes that the patient was oriented to the project's policies.
These clients have signed the appropriate paperwork acknowledging the above at the time of inspection.
The facility has changed the after hour admission process to ensure that this does not get missed in the future. |
709.62(c)(2)(ii) LICENSURE Orientation - Op hours
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the project's hours of operation, during the detox intake process, in three of seven client records reviewed.
Client #1 was admitted on August 5, 2022 and was still active at the time of the inspection.
Client #2 was admitted on August 6, 2022 and was still active at the time of the inspection.
Client #4 was admitted on August 2, 2022 and was discharged on August 9, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director is responsible for ensuring that all documentation at time of admission/intake is completed and signed by the patient and staff witness, as appropriate. This includes that the patient was oriented to the project's hours of operation.
These clients have signed the appropriate paperwork acknowledging the above at the time of inspection.
The facility has changed the after hour admission process to ensure that this does not get missed in the future. |
709.62(c)(2)(iii) LICENSURE Orientation - Fee Schedule
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the project's fee schedule, during the detox intake process, in three of seven client records reviewed.
Client #1 was admitted on August 5, 2022 and was still active at the time of the inspection.
Client #2 was admitted on August 6, 2022 and was still active at the time of the inspection.
Client #4 was admitted on August 2, 2022 and was discharged on August 9, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director is responsible for ensuring that all documentation at time of admission/intake is completed and signed by the patient and staff witness, as appropriate. This includes that the patient was oriented to the project's fee schedule.
These clients have signed the appropriate paperwork acknowledging the above at the time of inspection.
The facility has changed the after hour admission process to ensure that this does not get missed in the future. |
709.62(c)(2)(iv) LICENSURE Orientation - Services Provided
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document that the client was oriented to the project's provided services, during the detox intake process, in three of seven client records reviewed.
Client #1 was admitted on August 5, 2022 and was still active at the time of the inspection.
Client #2 was admitted on August 6, 2022 and was still active at the time of the inspection.
Client #4 was admitted on August 2, 2022 and was discharged on August 9, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director is responsible for ensuring that all documentation at time of admission/intake is completed and signed by the patient and staff witness, as appropriate. This includes that the patient was oriented to the project's provided services.
These clients have signed the appropriate paperwork acknowledging the above at the time of inspection.
The facility has changed the after hour admission process to ensure that this does not get missed in the future. |