INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on January 28, 2025 through January 29, 2025 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:
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Plan of Correction
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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.
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Observations
Based on an administrative review of the February 2024 through December 2024 fire drill logs, the facility failed to ensure all their written fire drill logs included the exit route used during the drills. At the time of the review, the exit route used during the drill was not documented on the February 2024 through August 2024 fire drill logs.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of September 2024, the facility has updated fire drill logs to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of September 2024. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, audited quarterly under the hospital Environment of Care (EOC) Safety program. 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 Facilities Director is ultimately responsible for compliance with this standard. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to document an individual's emergency contact as part of the verification of their identity prior to the administration of a medication agent in four of twenty-two patient applicable patient records reviewed. Patient #10 was admitted to the inpatient hospital activity on January 8, 2025 and was discharged on January 27, 2025. There was no documentation of the patient's emergency contact in the record at the time of the inspection. Patient #20 was admitted to the inpatient non-hospital detoxification activity on December 14, 2024 and was discharged on December 22, 2024. There was no documentation of the patient's emergency contact in the record at the time of the inspection. Patient #21 was admitted to the inpatient non-hospital activity on January 28, 2025 and was active at the time of the inspection. There was no documentation of the patient's emergency contact in the record at the time of the inspection. Patient #25 was admitted to the inpatient non-hospital activity on December 22, 2024 and was discharged on December 26, 2024. There was no documentation of the patient's emergency contact in the record at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 20, 2025, the facility has updated the consent paperwork to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of March 31, 2025. Updated educational materials will accompany the workflow updates. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Executive Director is ultimately responsible for compliance with this standard. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to ensure the narcotic treatment physician documented the basis for the determination of current dependency in the patient ' s record in two of twenty-two applicable patient records reviewed. Patient # 10 was admitted to the inpatient hospital activity on January 8, 2025 and was discharged on January 27, 2025. The initial face-to-face meeting with the narcotic treatment physician was completed on January 8, 2025, however, there was no documentation in the record indicating the patient was currently physiologically dependent upon a narcotic drug.Patient # 21 was admitted to the inpatient non-hospital activity on January 28, 2025 and was still active at the time of the inspection. The initial face-to-face meeting with the narcotic treatment physician was completed on January 8, 2025, however, there was no documentation in the record indicating the patient was currently physiologically dependent upon a narcotic drug.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 18, 2025, Staff responsible for the completion of this standard have been trained on the workflow and compliance expectations. Training materials and procedures will be reviewed and revised as determined appropriate by March 31, 2025. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Medical Director is ultimately responsible for 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 facility failed to ensure all the required regulatory statements were included on the informed, voluntary, written consent to treat form in twenty-two of twenty-two patient records reviewed.Every patient record reviewed had a patient-signed informed consent to treat with an agent form; however, each patient consent to treat form did not include the notification to the patient that there alternative methods of treatment exist.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 20, 2025, the facility has updated the consent paperwork to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of March 31, 2025. Updated educational materials will accompany the workflow updates. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Executive Director is ultimately responsible for compliance with this standard. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to document the completion of an initial drug-screening analysis for each prospective patient in two of twenty-two patient records reviewed. Patient #6 was admitted to the inpatient hospital detoxification activity on July 19, 2024 and was discharged on July 25, 2024. The physician first prescribed the maintenance medication to the patient on July 19, 2024. The first urinalysis drug-screen documented in the record was completed on August 18, 2024, which was after the patient's first dose.Patient #14 was admitted to the inpatient hospital activity on July 25, 2024 and was discharged on August 22, 2024. The physician first prescribed the maintenance medication to the patient on July 19, 2024. The first urinalysis drug-screen documented in the record was completed on August 18, 2024, which was after the patient's first dose.These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 18, 2025, Staff responsible for the completion of this standard have been trained on the workflow and compliance expectations. Training materials and procedures will be reviewed and revised as determined appropriate by March 31, 2025. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Medical Director is ultimately responsible for 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 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 in one of one applicable patient record reviewed. Patient #26 was admitted to the inpatient non-hospital activity on August 22, 2024 and was transferred to another narcotic treatment program on September 5, 2024. 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 annual licensing renewal inspection.This finding was 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. |
711.62(c)(2)(i) LICENSURE Name of Person/agency/organization
711.62. 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:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made to on consent to release information forms in five of five client records reviewed. Every client record reviewed from the inpatient non-hospital detoxification activity had a client-signed release of information form that was blank, and each release form did not include documentation of the name of the person, agency, or organization to whom disclosure would be made.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 20, 2025, the facility has updated the consent paperwork to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of March 31, 2025. Updated educational materials will accompany the workflow updates. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Executive Director is ultimately responsible for compliance with this standard. |
711.62(c)(2)(ii) LICENSURE Specific Information Disclosed
711.62. 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 consent to release information forms in five of five client records reviewed. Every client record reviewed from the inpatient non-hospital detoxification activity had a client-signed release of information form that was blank, and each release form did not include documentation of the specific information to be disclosed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 20, 2025, the facility has updated the consent paperwork to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of March 31, 2025. Updated educational materials will accompany the workflow updates. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Executive Director is ultimately responsible for compliance with this standard. |
711.62(c)(2)(iii) LICENSURE Purpose of Disclosure
711.62. 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:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in five of five client records reviewed. Every client record reviewed from the inpatient non-hospital detoxification activity had a client-signed release of information form that was blank, and each release form did not include documentation the purpose of the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 20, 2025, the facility has updated the consent paperwork to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of March 31, 2025. Updated educational materials will accompany the workflow updates. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Executive Director is ultimately responsible for compliance with this standard. |
711.62(c)(3) LICENSURE Client's copy of consent
711.62. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in five of five client records reviewed. Every client record reviewed from the inpatient non-hospital detoxification activity had a client-signed release of information form that was blank, and there was no documentation in the record indicating that a copy of the release form was offered to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 20, 2025, the facility has updated the consent paperwork to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of March 31, 2025. Updated educational materials will accompany the workflow updates. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Executive Director is ultimately responsible for compliance with this standard. |
711.63(b) LICENSURE Promoting Client Interest in TX
711.63. Project management services.
(b) There shall be a written plan that delineates specific service planning and counseling approaches used to promote patient interest in participating in necessary treatment, following the detoxification process.
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Observations
Based on a review of patient records, the facility failed to follow their written plan which delineates the specific service planning and counseling approaches used to promote patient interest in participating in necessary treatment following the detoxification process in one of one applicable patient record reviewed.The facility's policy and procedure manual documented the emergency contact would be notified within 12 hours after a patient is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.Patient #16 was admitted to the inpatient non-hospital detoxification activity on October 13, 2024 and was discharged against medical advice on October 13, 2024. At the time of the inspection, there was no documentation, in the record, indicating the emergency contact was notified upon the patient's discharge against medical advice. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of March 31, 2025, Staff responsible for the completion of this standard will be trained on the workflow and compliance expectations. Training materials and procedures will be reviewed and revised as determined appropriate by March 31, 2025. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Nursing Director is ultimately responsible for compliance with this standard. |
7141.52(c) LICENSURE Treatment Plan
711.52. Treatment and rehabilitation services.
(c) 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 patient records, the facility failed to ensure individual treatment and rehabilitation plans were developed with the patient in two of five applicable patient records reviewed. Patient # 22 was admitted to the inpatient non-hospital activity on October 3, 2024 and was discharged on October 12, 2024. There was no individual treatment and rehabilitation plan documented in the record at the time of inspection. Patient # 24 was admitted to the inpatient hospital activity on January 22, 2025 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of March 31, 2025, the facility will review the written policies and procedures for treatment and rehabilitation planning documentation to ensure that the written protocols address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the workflow and compliance expectations as of March 31, 2025. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 compliance with this standard. |
711.53(c)(2)(i) LICENSURE Person/Agency/Org to Whom Disclosure Made
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:
(i) The name of the person, agency, organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made to on consent to release information forms in seven of seven client records reviewed. Every client record reviewed from the inpatient non-hospital activity had a client-signed release of information form that was blank, and each release form did not include documentation of the name of the person, agency, or organization to whom disclosure would be made.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 20, 2025, the facility has updated the consent paperwork to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of March 31, 2025. Updated educational materials will accompany the workflow updates. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Executive Director is ultimately responsible for 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 consent to release information forms in seven of seven client records reviewed. Every client record reviewed from the inpatient non-hospital activity had a client-signed release of information form that was blank, and each release form did not include documentation of the specific information to be disclosed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 20, 2025, the facility has updated the consent paperwork to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of March 31, 2025. Updated educational materials will accompany the workflow updates. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Executive Director is ultimately responsible for compliance with this standard. |
711.53(c)(2)(iii) LICENSURE Purpose of Disclosure
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:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in seven of seven client records reviewed. Every client record reviewed from the inpatient non-hospital activity had a client-signed release of information form that was blank, and each release form did not include documentation the purpose of the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 20, 2025, the facility has updated the consent paperwork to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of March 31, 2025. Updated educational materials will accompany the workflow updates. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Executive Director is ultimately responsible for compliance with this standard. |
711.53(c)(3) LICENSURE Copy of Client Consent
711.53. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in seven of seven client records reviewed. Every client record reviewed from the inpatient non-hospital activity had a client-signed release of information form that was blank, and there was no documentation in the record indicating that a copy of the release form was offered to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 20, 2025, the facility has updated the consent paperwork to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of March 31, 2025. Updated educational materials will accompany the workflow updates. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Executive Director is ultimately responsible for compliance with this standard. |
710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of patient records, the facility failed to keep patient records confidential in accordance with applicable Federal drug and alcohol regulations in seven of seven applicable inpatient hospital detoxification patient records reviewed.Every inpatient hospital detoxification patient record reviewed had a blank client-signed release of information form documented in the record. The blank release of information form did not include documentation of the description of the information to be used or disclosed, the name of the person, or class of persons, to which a disclosure is to be made, and the purpose of the requested use or disclosure, per the requirement in the Federal 42 CFR Part 2 confidentiality regulations.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of February 20, 2025, the facility has updated the consent paperwork to address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the updated workflow and compliance expectations as of March 31, 2025. Updated educational materials will accompany the workflow updates. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 Executive Director is ultimately responsible for 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 ensure individual treatment and rehabilitation plans were developed with the patient in three of six applicable patient records reviewed. Patient # 9 was admitted to the inpatient hospital activity on January 9, 2025 and was still active at the time of inspection. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection. Patient # 12 was admitted to the inpatient hospital activity on September 27, 2024 and was discharged on October 3, 2024. There was no individual treatment and rehabilitation plan documented in the record at the time of inspection. Patient # 13 was admitted to the inpatient hospital activity on August 31, 2024 and was discharged on September 10, 2024. There was no individual treatment and rehabilitation plan documented in the record at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of March 31, 2025, the facility will review the written policies and procedures for treatment and rehabilitation planning documentation to ensure that the written protocols address the deficiency identified in the licensing inspection. Staff responsible for the completion of this paperwork will be trained on the workflow and compliance expectations as of March 31, 2025. Compliance with this standard will be continuously monitored within the department on an ongoing basis, and as appropriated, 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 compliance with this standard. |