INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17, 2021 through August 19, 2021 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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704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on an administrative review of the facility-submitted Staffing Requirements Facility Summary Report and the client census, the facility failed to ensure that the inpatient nonhospital detoxification services have one (full-time equivalent) FTE primary care staff person available for every seven (7) clients during primary care hours.
On Friday, July 23, 2021, from the hours of 12AM to 1PM and 7PM to 11PM, there were 10 detox clients and one primary care staff person available. On Saturday, July 24, 2021, from the hours of 12AM to 7AM and 7PM to 11PM, there were 8 detox clients and one primary care staff person available.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director is responsible for ensuring appropriate staffing 24/7 in our facility. Based on the fluctuation of patients in the detox activity, Avenues has contracted with a nursing agency to ensure proper coverage to maintain a 1:7 ratio at all times. Based on the census, scheduling will be adjusted and adhered to to ensure proper coverage. The Executive Director is actively recruiting and interviewing to hire more full time nurses to ensure there is no lapse in coverage in the event the nursing agency is unable to assist. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on August 17, 2021, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
There was one camera located in the lower-level group room and two cameras located in the main floor group room, all of which allow for counseling sessions to be video-taped and seen outside the counseling room.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of IT is responsible for safely removing the cameras from the mutli-purpose group rooms to ensure that counseling sessions cannot be seen or heard. |
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 client records, the facility failed to follow the written procedures for the management of treatment and rehabilitation services for clients.
There was documentation in the client records that indicated that the facility was combining non-residential (partial hospitalization and outpatient) with residential activities (detox and residential). The facility was permitting clients who were admitted into the non-residential activities to attend group therapy sessions designed for the residential client, even though the clients were admitted to distinct and separate treatment activities.
The Director of Operations and VP of Operations, in consult with the Executive Director, confirmed that non-residential clients attend group therapy at the residential treatment program throughout the clients' treatment episodes. Additionally, there were documented progress notes in the non-residential client records of attendance to the daily programming group sessions intended the residential clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director is responsible for keeping both residential and non-residential groups completely separate. At present, Avenues has a separate entrance for non-residential patients to enter the building so that they do not cross paths with residential patients. The staff has been retrained on the importance of keeping residential and non-residential patients separate. The Clinical Director has revamped the program schedule to ensure that they do not attend the same groups and are kept completely separate at all times. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of twenty-five client records reviewed.
Client # 11 was admitted to the residential level of care on May 26, 2021 and discharged on June 23, 2021. There was documentation of a family session with the client's sister on June 23, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
This is a repeat citation from the January 7, 2021 annual renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff was retrained on confidentiality laws pertaining to DDAP regulations in section 709, 4 Pa Code 255.5, HIPAA, and 42 CFR Part 2. All staff has been notified that 'inferred consent' is not acceptable and all those participating in a family session need a written consent. The Clinical Director is responsible for ensuring compliance with the confidentiality laws and making sure that all appropriate releases are signed for prior to the start of any family sessions. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on consent to release information forms in two of twenty-five client records reviewed.
Client # 4 was admitted to the detox level of care on May 19, 2021 and was discharged on May 26, 2021. A release of information form to an outside individual was signed and dated by the client on May 20, 2021, however, the purpose of the disclosure was not documented on the release form.
Client # 11 was admitted to the residential level of care on May 26, 2021 and was discharged on June 23, 2021. A release of information form to an outside individual was signed and dated by the client on May 20, 2021, however, the purpose of the disclosure was not documented on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff was retrained on confidentiality laws as well as how to completely and accurately fill out a consent to release information so that all identifying areas, including the purpose of disclosure, are addressed and signed for by both the patient and the witness. All staff has acknowledged that they understand the rationale and importance of completely and accurately completing a consent to release information. The Clinical Director is responsible for ensuring that all forms within the EMR, including a consent to release information, is completely filled out. The Clinical Director will review charts on a weekly basis to ensure compliance at all times. |
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
Based on a review of client record, the facility failed to document the dated signature of a witness on release of information forms in one of twenty-five client records reviewed.
Client # 21 was admitted to the partial hospitalization level of care on April 13, 2021 and was discharged on April 22, 2021. A release of information form to a physician was signed and dated by the client on April 20, 2021; however, the release form did not document the dated signature of witness.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff was retrained on confidentiality laws as well as how to completely and accurately fill out a consent to release information so that all identifying areas, including the need for a witness signature. All staff has acknowledged that they understand the rationale and importance of signing as a witness on a consent to release information. The Clinical Director is responsible for ensuring that all consents to release information have a witness signature. The Clinical Director will review charts on a weekly basis to ensure compliance at all times. |
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
Based on a review of client records, the facility failed to ensure that a copy of a client consent to release information form was offered to the client in five of twenty-five client records reviewed.
Client # 13 was admitted to the residential level of care on July 12, 2021 and was discharged on August 16, 2021. A release of information form to another treatment provider was signed and dated by the client on July 13, 2021; however, there was no documentation that a copy was offered to the client. Additionally, a release of information form to a physician was signed and dated by the client on July 12, 2021; however, there was no documentation that a copy was offered to the client.
Client # 14 was admitted to the residential level of care on May 15, 2021 and was discharged on June 18, 2021. A release of information form to another treatment provider was signed and dated by the client on May 15, 2021; however, there was no documentation that a copy was offered to the client.
Client # 17 was admitted to the partial hospitalization level of care on April 26, 2021 and was discharged on May 26, 2021. A release of information form to the funding source and to a hospital were signed and dated by the client on April 21, 2021; however, there was no documentation that a copy of either form was offered to the client.
Client # 18 was admitted to the partial hospitalization level of care on June 17, 2021 and was discharged on July 16, 2021. A release of information form to the funding source was signed and dated by the client on June 11, 2021; however, there was no documentation that a copy was offered to the client. Additionally, release of information forms to two treatment providers were signed and dated by the client on June 13, 2021; however, there was no documentation that a copy of either form was offered to the client.
Client # 20 was admitted to the partial hospitalization level of care on March 8, 2021 and was discharged on March 25, 2021. Release of information forms to another treatment provider, a funding source, and a hospital were all signed and dated by the client on February 2, 2021; however, there was no documentation that a copy of any of the forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff was retrained on confidentiality laws as well as how to completely and accurately fill out a consent to release information so that all identifying areas, including offering a copy to the patient, has been recorded. All staff has acknowledged that they understand the rationale and importance of offering a consent to release to the patient. The Clinical Director is responsible for ensuring that all consents to release information have it checked off that the client was offered a copy. The Clinical Director will review charts on a weekly basis to ensure compliance at all times. |
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
Based on a review of client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client in two of four applicable client records reviewed.
Client # 23 was admitted to the outpatient level of care on July 15, 2021 and was still active at the time of inspection. The outpatient treatment plan was not documented until July 28, 2021, which is after the facility's written policy on developing a treatment plan.
Client # 25 was admitted to the outpatient level of care on January 18, 2021 and was discharged on February 13, 2021. There was no documentation of an outpatient treatment plan in the record for the entire duration of the treatment episode.
This is a repeat citation from the January 7, 2021 annual renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director is responsible for ensuring that there are complete and comprehensive treatment and rehabilitation plans on every patient in all levels of care. The facility has rolled out a 'caseload tracker' that identifies needs in the patient records, including treatment and rehabilitation plans in the outpatient level of care. The Clinical Director is responsible for reviewing the caseload tracker and all charts. The Clinical Director will review charts on a weekly basis to ensure that all patient records have the required documentation in them on any given day. |