INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on February 2, 2026 through February 4, 2026 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 Medical Center At Valley Forge DBA Valley Forge Medical Center 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:
|
Plan of Correction
|
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.
|
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 2025 through December 2025 training year in one of four applicable personnel records reviewed. Employee # 5 was hired as a counselor on April 4, 2023. The personnel record documented 10.75 hours of annual training during the reviewed period. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 2/6/2026, The Compliance Department scheduled quarterly reviews with Human Resources to conduct and verify each counselor's year-to-date training hours and category compliance under 704.11(f)(2). Human Resources will assign 25 clock hours of annual training to each counselor at the start of the training year. Training will be assigned within approved regulatory categories. HR will maintain a centralized training log documenting hours completed, dates, and subject areas. Counselors will be monitored to ensure progress toward completion of 25 hours by year-end. Counselors not meeting quarterly benchmarks will be taken off schedule until they meet requirements. Counselors will be expected to complete approximately:
6.25 hours per quarter
12.5 hours by mid-year
18.75 hours by Q3
25 hours by year-end
The facility anticipates full compliance within 30 days of Plan of Correction approval and will maintain compliance ongoing thereafter through quarterly monitoring and documented oversight. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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.
|
Observations
Based on a review of the facility's March 2025 through December 2025 fire drill logs, the facility failed to ensure the exit route used was documented on all completed, written fire drill records.At the time of the inspection, the log for the fire drill conducted during October 2025 did not include documentation of which exit route was used during the drill. This is a repeat citation from the January 29, 2025 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As per regulation, the fire drill documentation will be updated to clearly identify the exit routes used during each drill.
Staff responsible for conducting and documenting fire drills have been educated on how to properly complete the form.
The Director of Facilities will review fire drill documentation after each drill to ensure all required elements, including exit routes used, are documented appropriately. Any omissions will be corrected promptly.
Monitoring to Ensure Ongoing Compliance
Compliance will receive and review fire drill logs at least quarterly for proper review and storage.
Compliance with this standard will be monitored within the department on an ongoing basis and, as appropriate, audited quarterly under the hospital Safety/Environment of Care Committee meeting to ensure 100% compliance has been established.
|
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of the facility's March 2025 through December 2025 fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. At the time of the inspection, there was no documentation indicating any fire drills were conducted during the facility's sleeping hours throughout the reviewed period.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility will conduct at least one fire drill during sleeping hours every six (6) months.
Sleeping-hour drills will occur during overnight hours (11pm-8am) when residents are in bed. Drills will simulate realistic conditions.
Staff Responsibilities
The Director of Facilities or designee will ensure sleeping-hour fire drills are scheduled and completed.
Overnight staff will be trained on fire response procedures, evacuation routes, and resident assistance during admission orientation and annual training.
Documentation
Fire drill logs will clearly identify:
Whether the drill occurred during sleeping or waking hours, date and time of the drill, names of staff conducting the drill, patients participation, any issues identified and corrective actions taken, documentation will be maintained on-site and available for DDAP review.
Monitoring to Ensure Ongoing Compliance
Compliance will receive and review fire drill logs at least quarterly.
Sleeping-hour drills are conducted at least every six (6) months.
|
711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for failing to transfer the patient file to a receiving narcotic treatment program was submitted and approved by the Department for the February 6, 2024, August 6, 2024, and January 29, 2025, annual licensing inspection. Failing to transfer the patient file to a receiving narcotic treatment program was again found to be a deficiency in the February 2, 2026 through February 4, 2026, annual licensing inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility has reviewed this finding with staff and is implementing the following revised Plan of Correction to ensure full compliance moving forward:
Plan of Correction:
In accordance with the regulation, when a patient transfers from our facility to another narcotic treatment program (NTP), staff will transfer the complete patient file to the receiving program.
To ensure compliance:
1. Staff have been re-educated on discharge and transfer procedures.
2. The Director of Case Management will review all outgoing NTP transfer records to confirm:
* The transfer packet was sent to the receiving facility
* Documentation of the transfer is present in the electronic medical record (EMR)
* Patient consent for release of information is included
If any required documentation is missing, it will be corrected promptly and addressed directly with the responsible staff member. The Director of Case Management will be ultimately responsible for ensuring compliance with this standard.
Compliance will be monitored internally on an ongoing basis until 3 months of full compliance. Additionally, this process will be audited monthly under the hospital's Quality Assurance and Performance Improvement (QAPI) program for 6 months to ensure sustained compliance.
|
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
Based on a review of patient records, the facility failed to ensure the narcotic treatment physician who completed the patient examination consulted with the narcotic treatment physician who determined the initial dose in ten of nineteen applicable patient records reviewed.Patient # 1 was admitted to the inpatient hospital detoxification activity on January 29, 2026 and was still active at the time of the inspection. The initial patient examination was completed by the physician assistant on January 29, 2026 and the medical doctor ordered the first dose; however, there was no consultation documented in the record at the time of the inspection. Patient # 4 was admitted to the inpatient hospital detoxification activity on January 22, 2026 and was discharged on January 28, 2026. The initial patient examination was completed by the physician assistant on January 22, 2026 and the medical doctor ordered the first dose; however, there was no consultation documented in the record at the time of the inspection.Patient # 5 was admitted to the inpatient hospital detoxification activity on January 20, 2026 and was discharged on January 25, 2026. The initial patient examination was completed by the physician assistant on January 20, 2026 and the medical doctor ordered the first dose; however, there was no consultation documented in the record at the time of the inspection.Patient # 6 was admitted to the inpatient hospital detoxification activity on January 22, 2026 and was discharged on January 27, 2026. The initial patient examination was completed by the physician assistant on January 22, 2026 and the medical doctor ordered the first dose; however, there was no consultation documented in the record at the time of the inspection.Patient # 12 was admitted to the inpatient hospital activity on December 18, 2025 and was discharged on January 15, 2026. The initial patient examination was completed by the physician assistant on December 19, 2025 and the medical doctor ordered the first dose; however, there was no consultation documented in the record at the time of the inspection.Patient # 16 was admitted to the inpatient non-hospital detoxification activity on September 19, 2025 and was discharged on September 24, 2025. The initial patient examination was completed by a certified registered nurse practitioner on September 19, 2025 and a different certified registered nurse practitioner ordered the first dose; however, there was no consultation documented in the record at the time of the inspection.Patient # 17 was admitted to the inpatient non-hospital detoxification activity on November 15, 2025 and was discharged on November 24, 2025. The initial patient examination was completed by the physician assistant on November 16, 2025 and the medical doctor ordered the first dose; however, there was no consultation documented in the record at the time of the inspection.Patient # 24 was admitted to the inpatient non-hospital activity on January 21, 2026 and was active at the time of the inspection. The initial patient examination was completed by the physician assistant on January 21, 2026 and the medical doctor ordered the first dose; however, there was no consultation documented in the record at the time of the inspection.Patient # 25 was admitted to the inpatient non-hospital activity on January 24, 2026 and was active at the time of the inspection. The initial patient examination was completed by the physician assistant on January 24, 2026 and the medical doctor ordered the first dose; however, there was no consultation documented in the record at the time of the inspection.Patient # 27 was admitted to the inpatient non-hospital activity on November 16, 2025 and was discharged on November 17, 2025. The initial patient examination was completed by a certified registered nurse practitioner on November 16, 2025 and a different certified registered nurse practitioner ordered the first dose; however, there was no consultation documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As per regulation, when different physicians complete the H&P and determine the initial dose, a brief consultation note will be entered into the patient's medical record prior to dosing.
A standard consultation note requirement will be implemented for all cases in which:
*One physician completes the H&P, and
*A different physician determines the initial dose.
Monitoring to Ensure Ongoing Compliance
- The Medical Director will review initial dose documentation to confirm the presence of a consultation note when applicable.
- Upon review, any missing documentation will be corrected immediately and addressed with the responsible provider(s).
Compliance with this standard will be monitored within the department on an ongoing basis until compliance has been established for a 3-month timeperiod and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program for 6 months to ensure compliance has been established.
|
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to ensure the transfer of patient files, which is to include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, to a receiving narcotic treatment program upon the transfer of a patient in one of two applicable patient records reviewed. Patient # 12 was admitted to the inpatient hospital activity on December 18, 2025 and was transferred to another narcotic treatment program on January 15, 2026. There was no documentation in the record indicating the receiving narcotic treatment program was notified of the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient. This is a repeat citation from the February 6, 2024, August 6, 2024, and January 29, 2025 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As per regulation, when a patient transfers from our facility, to another narcotic treatment program, staff will transfer the patient files to their outward-bound facility.
Director of Case Management will review all outgoing NTP transfer records to confirm:
- The transfer packet was sent
- Documentation is present in the EMR
- Patient consent is included
Upon the director's review, any missing documentation will be corrected promptly and addressed with the responsible staff. Ultimately, the Director of Case Management will be responsible for ensuring compliance with this standard.
Compliance with this standard will be monitored within the department on an ongoing basis until compliance has been established for 3 months and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program for 6 months to ensure 100% compliance has been established.
|
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient records reviewed. Patient # 3 was transferred in and admitted to the inpatient hospital detoxification activity on June 4, 2025 and was discharged on June 9, 2025. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the patient's date of admission and the date the initial dose was given. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As per regulation, when a patient transfers into the facility from another licensed NTP, staff will notify the prior NTP of:
- Patient admission, and
- Date of the initial dose administered by our facility.
Notification and dosing will be documented using the First Dose Verification Form, sent to the previous NTP, and placed in the patient's electronic medical record.
This requirement applies only to licensed NTPs and does not apply to emergency departments or acute-care hospitals without NTP licensure.
Case Management staff will be responsible for completing the form at the time of the initial dose and for documenting prior NTP notification.
Monitoring to Ensure Ongoing Compliance
The Director of Case Management will audit a sample size of patient charts for compliance. Any missing documentation will be corrected promptly and addressed with the responsible staff. Ultimately, the Director of Case Management will be responsible for ensuring compliance with this standard.
Compliance with this standard will be monitored within the department on an ongoing basis until compliance has been established for 3 months, and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program for 6 months to ensure compliance has been established. |