INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 2026 through February 24, 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 Center of Lake Ariel, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee # 3 was hired as a counselor on May 28, 2024 and was due to have TB/STD training no later than May 28, 2025; however, the TB/STD training was not completed until September 4, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Administrator is responsible for ensuring that all counselors receive 4 hours of TB/STD training with a DDAP approved curriculum within one year of hire for counselors and within 2 years of hire for all other staff. Employees continue to struggle with signing up through the training website. The Director of Medical Development and Corporate Medical Director will work to create training courses with DDAP approved curriculum to ensure that all employees obtain the required hours for TB/STD training timely. Until the course development, Avenues will continue to contract an approved instructor on a semi-annual basis vs annually to ensure timely completion. All other employees are currently compliant with this regulation. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in two of fifteen client records reviewed.
Client # 1 was admitted to the inpatient non-hospital detoxification activity on February 17, 2026 and was still active at the time of the inspection. There was evidence of disclosure to a family member on February 17, 2026; however, the consent to release information form was not signed by the client until February 19, 2026.
Client # 6 was admitted to the inpatient non-hospital detoxification activity on February 4, 2026 and was discharged on February 11, 2026. There was evidence of disclosure to a family member on February 5, 2026; however, the consent to release information form was not signed by the client until February 6, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The new intake staff was misinformed that verbal consent was permissible when making a safe call with the patients. The Executive Director (ED) retrained staff on confidentiality laws and ensuring that no calls are made prior to patient's written consent. All new employees are trained in confidentiality laws as part of new hire orientation and annually. The ED will continue to ensure compliance. The chart auditor will also escalate any deviation from rule to the ED for further education. |