INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on February 5, 2024 through February 6, 2024 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 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure that a counselor assistant with a high school diploma counseled clients only under the direct supervision of a trained counselor or clinical supervisor for the first 3 months of employment in one of one applicable personnel record reviewed.
Employee #13 was hired as a counselor assistant on January 2, 2024 and was counseling clients at the time of the inspection. There was no documentation, in the personnel record, that indicated a clinical supervisor or trained counselor provided any direct supervision of the employee since the employee ' s start date.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has provided education to staff responsible for the documentation of direct supervision and have implemented changes to the format of documentation of direct supervision of counselor assistants. Compliance with this standard will be monitored within the department on an ongoing basis and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program until 90% compliance has been established. Evidence of non-compliance will be addressed promptly by the departmental director. As appropriate, staff who are identified as not following the established workflow will receive additional training and be subject to the hospital's progressive disciplinary standards. The Clinical Director is ultimately responsible for ensuring compliance with this standard. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, conducted on February 6, 2024 at approximately 9:30am, the facility failed to keep the grounds of the facility clean, safe sanitary and in good repair at all times for the safety and well-being of residents, employees, and visitors.
At the time of the inspection, the following issues were observed:
Second-floor gym/physical therapy room, there was a window screen with large holes in it.
Bedroom 204 had chipped flooring leading into the bathroom.
Bedroom 206 had cracked and chipped flooring.
Bedroom 212 had peeling wallpaper and dirty, soiled divider curtains.
Bedroom 217 had a ceiling corner that was cracked, had peeling paint, and was missing plaster.
Bedroom 218 had peeling wallpaper.
Bedroom 222 had the appearance of cobwebs in the upper right corner of the window blinds.
Bedroom 225 had exposed piping and wiring under the air conditioner unit and the floor was missing several tiles.
Bedroom 227 had a chipped chair railing.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The identified deficiencies were addressed as follows:
Second floor gym window screen ? replaced on 2/7/24
Bedroom 204 (cited in error, picture provided by DDAP is Room 206) ? and sealed on 3/2/24
Bedroom 206 ?replaced on 3/4/24
Bedroom 212 ?will be replaced by 3/29/24
Bedroom 217 ?repaired on 3/5/24
Bedroom 218 ?repaired on 3/5/24
Bedroom 222 ? cleaned on 3/4/24
Bedroom 225 ? framing was built around air conditioner on 3/8/24
Bedroom 227 ? will be repaired by 3/29/24
Ongoing environmental surveys of the facility have been implemented to quickly identify deficiencies and report such deficiencies for repair. Compliance with this standard continues to be monitored within the department on an ongoing basis and audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program until 90% compliance has been established, and quarterly thereafter. Evidence of non-compliance will be addressed promptly by the departmental director. As appropriate, staff who are identified as not following the established workflow will receive additional training and be subject to the hospital's progressive disciplinary standards. The Director of Facilities is ultimately responsible for ensuring compliance with this standard.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, conducted on February 6, 2024 at approximately 9:30am, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
The following bathrooms were found to be either not clean, sanitary, or non-functional at the time of the inspection:
The bathroom in bedroom 204 had cracked and missing tiles within the shower stall.
The bathroom in bedrooms 204, 205, 211, 214, 216 and 223 had what appeared to be mold in the showers and around the bathroom ceiling itself.
The bathroom in bedroom 211 had a hole in the shower wall.
The bathroom in bedroom 212 had a shower stall that was chipped.
The bathroom in bedroom 215 had rust on the pipes and on the shower rod.
The bathroom in bedroom 214 had damaged drywall and holes in the shower walls.
The bathroom in bedroom 216 had a damaged door handle plate that was loose.
The bathroom in bedroom 219 had a cracked and buckling shower stall above the faucet and a wall covering, under the toilet paper dispenser, that was cracked and pulling away from the wall.
The bathrooms in bedrooms 220 and 225 had broken toilet paper holders.
The bathroom in bedroom 223 had a hole in the outside part of the bathroom door.
This is a repeat citation from the March 9, 2022 through March 10, 2022 and February 27, 2023 through March 1, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The identified deficiencies were addressed as follows:
Bathroom 204 ? Tiles will be repaired and resealed by 3/29/24
Bathrooms 204, 205, 211, 214, 216, 223 ? Mold will be removed and showers will be resealed by 3/22/24
Bathroom 211 ? Hole will be resealed by 3/29/24
Bathroom 212 ? Shower will be repaired by 3/29/24
Bathroom 214 ? Rust will be removed and pipes will be resealed; Rod will be replaced by 3/29/24
Bathroom 215 ? Hole will be repaired and resealed by 3/29/24
Bathroom 216 ? Door Handle will be repaired by 3/29/24
Bathroom 219 ? Walls were repaired and resealed on 3/7/24
Bathroom 220 ? Dispensers were found intact. Old tiled dispensers were still installed.
Bathroom 223 ? Door repaired on 3/8/24
Ongoing environmental surveys of the facility have been implemented to promptly identify deficiencies and report such deficiencies for repair. Compliance with this standard continues to be monitored within the department on an ongoing basis and audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program until 90% compliance has been established, and quarterly thereafter. Evidence of non-compliance will be addressed promptly by the departmental director. As appropriate, staff who are identified as not following the established workflow will receive additional training and be subject to the hospital's progressive disciplinary standards. The Director of Facilities is ultimately responsible for ensuring compliance with this standard.
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715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure that each female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered in four of nine applicable patient records reviewed.
Patient #1 was admitted to the inpatient hospital detoxification activity on November 20, 2023 and was discharged on November 25, 2023. The patient was first administered a maintenance agent on November 21, 2023; however, there was no documentation in the record that indicated the female patient was fully informed of possible risks from use or withdrawal from a maintenance agent administered by the facility.
Patient #2 was admitted to the inpatient hospital detoxification activity on November 25, 2023 and was discharged on December 4, 2023. The patient was first administered a maintenance agent on November 26, 2023; however, there was no documentation in the record that indicated the female patient was fully informed of possible risks from use or withdrawal from a maintenance agent administered by the facility.
Patient #8 was admitted to the inpatient hospital activity on November 25, 2023 and was discharged on December 1, 2023. The patient was first administered a maintenance agent on November 21, 2023; however, there was no documentation in the record that indicated the female patient was fully informed of possible risks from use or withdrawal from a maintenance agent administered by the facility.
Patient #9 was admitted to the inpatient hospital activity on December 4, 2023 and was discharged on December 15, 2023. The patient was first administered a maintenance agent on November 26, 2023; however, there was no documentation in the record that indicated the female patient was fully informed of possible risks from use or withdrawal from a maintenance agent administered by the facility.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility implemented a workflow change prior to the date of the site visit to address this issue. Deficiencies noted are prior to the date of implementation of changes. Compliance with this standard continues to be monitored within the department on an ongoing basis and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program until 90% compliance has been established. Evidence of non-compliance will be addressed promptly by the departmental director. As appropriate, staff who are identified as not following the established workflow will receive additional training and be subject to the hospital's progressive disciplinary standards. The Director of Admissions is ultimately responsible for ensuring compliance with this standard. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for maintenance or detoxification treatment in four of fourteen applicable patient records reviewed.
Patient #1 was admitted to the inpatient hospital detoxification activity on November 20, 2023 and was discharged on November 25, 2023. The physician first prescribed maintenance medication to the patient on November 21, 2023; however, there was no consent to treat with a narcotic agent signed by the patient documented in the record prior to the first dose.
Patient #2 was admitted to the inpatient hospital detoxification activity on November 25, 2023 and was discharged on December 4, 2023. The physician first administered a maintenance agent on November 26, 2023; however, there was no consent to treat with a narcotic agent signed by the patient documented in the record prior to the first dose.
Patient #8 was admitted to the inpatient hospital activity on November 25, 2023 and was discharged on December 1, 2023. The physician first prescribed maintenance medication to the patient on November 21, 2023; however, there was no consent to treat with a narcotic agent signed by the patient documented in the record prior to the first dose.
Patient #9 was admitted to the inpatient hospital activity on December 4, 2023 and was discharged on December 15, 2023. The physician first administered a maintenance agent on November 26, 2023; however, there was no consent to treat with a narcotic agent signed by the patient documented in the record prior to the first dose.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility implemented a workflow change prior to the date of the site visit to address this issue. Deficiencies noted are prior to the date of implementation of changes. Compliance with this standard continues to be monitored within the department on an ongoing basis and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program until 90% compliance has been established. Evidence of non-compliance will be addressed promptly by the departmental director. As appropriate, staff who are identified as not following the established workflow will receive additional training and be subject to the hospital's progressive disciplinary standards. The Director of Admissions is ultimately responsible for ensuring compliance with this standard. |
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.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files, which is to include the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and also shall contain the written consent of the patient, to another narcotic treatment program in two of two applicable patient records reviewed.
Patient #8 was admitted to the inpatient hospital activity on November 25, 2023 and was discharged and transferred to another narcotic treatment program on December 1, 2023. There was no documentation in the record indicating any of the required record information was transferred to the other narcotic treatment program.
Patient #9 was admitted to the inpatient hospital activity on December 4, 2023 and was discharged on December 15, 2023. There was no documentation in the record indicating any of the required record information was transferred to the other narcotic treatment program.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has provided education to staff responsible for the documentation of transfer of records to other narcotic treatment programs. Compliance with this standard will be monitored within the department on an ongoing basis and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program until 90% compliance has been established. Evidence of non-compliance will be addressed promptly by the departmental director. As appropriate, staff who are identified as not following the established workflow will receive additional training and be subject to the hospital's progressive disciplinary standards. The Clinical Director is ultimately responsible for ensuring compliance with this standard. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the unusual incident logs, the narcotic treatment program failed to notify the Department within 48 hours of the physical abuse between two patients.
The narcotic treatment program was notified of the physical altercation between two patients on September 5, 2023; however, the incident was not reported to the Department until September 11, 2023.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will provide education by 3/22/24 to staff responsible for reporting unusual incidents regarding the required reporting timeframe. Compliance with this standard will be monitored within the department on an ongoing basis and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program until 90% compliance has been established. Evidence of non-compliance will be addressed promptly by the departmental director. As appropriate, staff who are identified as not following the established workflow will receive additional training and be subject to the hospital's progressive disciplinary standards. The Director of Quality & Compliance is ultimately responsible for ensuring compliance with this standard. |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information from the client for the disclosure of information contained in the client record in one of twenty-one client records reviewed.
Client #16 was admitted on January 18, 2024, and was active at the time of inspection. The client record included evidence of billing to the client's funding source; however, there was no consent to release information form to the funding source documented prior to any of the disclosures.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility implemented a workflow change prior to the date of the site visit to address this issue. Deficiencies noted are prior to the date of implementation of changes. Compliance with this standard continues to be monitored within the department on an ongoing basis and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program until 90% compliance has been established. Evidence of non-compliance will be addressed promptly by the departmental director. As appropriate, staff who are identified as not following the established workflow will receive additional training and be subject to the hospital's progressive disciplinary standards. The Director of Admissions is ultimately responsible for ensuring compliance with this standard. |
711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of twenty-one client records reviewed.
Client #15 was admitted on December 13, 2023, and was active at the time of inspection. The release of information form to a primary care physician was signed and dated by the client on December 13, 2023, but the release form did not include the specific information to be disclosed.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility implemented a workflow change prior to the date of the site visit to address this issue. Deficiencies noted are prior to the date of implementation of changes. Compliance with this standard continues to be monitored within the department on an ongoing basis and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program until 90% compliance has been established. Evidence of non-compliance will be addressed promptly by the departmental director. As appropriate, staff who are identified as not following the established workflow will receive additional training and be subject to the hospital's progressive disciplinary standards. The Director of Admissions is ultimately responsible for ensuring compliance with this standard. |
710.42(b)(1) LICENSURE Treatment and Rehabilitation Services
§ 710.42. Treatment and rehabilitation services.
(b) An individual treatment and rehabilitation plan shall be developed with each patient. This plan shall include, but not be limited to, written documentation of the following:
(1) Short and long-term goals for treatment as formulated by both staff and patient.
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Observations
Based on a review of patient records, the facility failed to document an individual treatment and rehabilitation plan, which shall be developed with each patient, in two of four applicable patient records reviewed.
Patient #8 was admitted to the inpatient hospital activity on November 25, 2023 and was discharged on December 1, 2023. There was no documentation, in the record, that an individual treatment and rehabilitation plan was completed prior to the patient's discharge.
Patient #9 was admitted to the inpatient hospital activity on December 4, 2023 and was discharged on December 15, 2023. There was no documentation, in the record, that an individual treatment and rehabilitation plan was completed prior to the patient's discharge.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility implemented a workflow change to address treatment plan updates to ensure they are completed timely. The facility has provided education to staff responsible for completing and updating treatment plans. Compliance with this standard will be monitored within the department on an ongoing basis and, as appropriate, audited monthly under the hospital Quality Assurance and Performance Improvement (QAPI) program until 90% compliance has been established. Evidence of non-compliance will be addressed promptly by the departmental director. As appropriate, staff who are identified as not following the established workflow will receive additional training and be subject to the hospital's progressive disciplinary standards. The Clinical Director is ultimately responsible for ensuring compliance with this standard. |