INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1, 2022 through February 2, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Recovery Center of America at Devon 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/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in two of thirteen applicable personnel records reviewed. Employee #5 was hired as a counselor on March 9, 2020 and promoted to clinical supervisor on August 15, 2021. Employee #5 was due to have the HIV/Aids training and the TB/STD training completed no later than March 9, 2021 (based on counselor position). There was no documentation of the completion of either training in the record as of the date of the inspection.Employee #42 was hired as a counselor on October 21, 2019 and was due to have HIV/AIDS training and TB/STD training no later than October 21, 2020. There was no documentation of the completion of the HIV/AIDS training in the record as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A tracking system will be implemented to monitor and notify staff members of their need to complete the Communicable Disease training by 3/1/22. This system will allow for both the staff member and their supervisor to be aware of the scheduled dates for the trainings as well as the staff members due date for the training. Three months prior to the due date, the supervisor of staff members will be notified of the pending due date and commit their staff member to one of the scheduled training dates. The Training Department will manage the tracking and scheduling of the Communicable Disease trainings. The staff member cited at the DDAP survey will complete both Communicable Disease trainings no later than 3/31/22. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2021 through December 31, 2021 training year in one of five applicable personnel records reviewed.Employee #40 was hired as a counselor on September 17, 2018. The personnel record documented 14 hours of training received during the training year reviewed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Training Department will track training hours for each clinical staff member. Effective 3/1/22, monthly reporting of training hours for the Clinical team will be provided to Clinical Supervisors and the Clinical Director. The Clinical Supervisors and Clinical Director will follow up with their team members on completing the required hours. The Training Department will notify the Executive Director of outstanding hours by October 15, 2022 for direct follow up with the Clinical Leadership. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client records reviewed.Client #8 was admitted into the partial hospitalization level of care on August 20, 2021 and was involuntarily discharged on September 2, 2021. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
If the client does not re-engage in services by the next scheduled day of programing, the site will continue to outreach via phone call on each day of missed programming for up to 5 consecutive sessions over the course of 7 days from the clients first missed visit.
a. In the event that client does not respond to outreach and re-engagement attempts the program will discharge the client and provide notification of discharge due to non-engagement.
Notification will occur via:
i. Phone call to client and collateral with active consents on file to notify of discharge and inform of process for re-admission to services. All correspondences will be documented.
ii. Discharge from Treatment letter will be mailed to the client in a plain envelope to client address on file.
Staff will be trained on these expectations on 3/23/2022 by the OP Director. Charts will be reviewed by Quality Assurance and the OP Director on a monthly basis starting 4/1/2022 and compliance will be monitored monthly as part of the site Medical Records Committee.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.Client #8 was admitted into the partial hospitalization level of care on August 20, 2021 and was involuntarily discharged on September 2, 2021. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The current discharge letter utilized by the site is being revised to include verbiage surrounding Involuntary Termination, including providing client with an opportunity to request reconsideration of the facility's decision to terminate treatment. The OP Director will be responsible for training and implementation of the letter, with completion expected by 3/31/2022.
Compliance will be tracked by chart reviews completed by Quality Assurance and the OP Director on a monthly basis starting 4/1/2022 and monitored monthly as part of the site Medical Records Committee.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to assure that clients admitted to the partial hospitalization program received individual counseling services at least twice a week in four of eight applicable client records reviewed. Client #1 was admitted into the partial hospitalization level of care on December 21, 2021 and was active at the time of inspection. The record of service and progress notes indicated that for the week of January 15-22, 2022, there was one individual session provided each week. Additionally, for the weeks of January 8-14, 2022 and January 22-29, 2022, there were no documented individual sessions provided.Client #3 was admitted into the partial hospitalization level of care on December 21, 2021 and was active at the time of inspection. The record of service and progress notes indicated that for the week of January 1-7, 2022, there was one individual session provided. Additionally, for the week of January 8-14, 2022, there was no documented individual sessions provided.Client #4 was admitted into the partial hospitalization level of care on December 16, 2020 and was discharged on January 13, 2021. The record of service and progress notes indicated that for the weeks of December 8-14, 2022 and December 26, 2021 - January 1, 2022, there were no documented individual sessions provided. Additionally, for the week of January 2-8, 2022, there was one individual session provided. Client #5 was admitted into the partial hospitalization level of care on April 26, 2021 and was discharged on May 24, 2021. The record of service and progress notes indicated that for the weeks of April 26-May 2, 2021 and May 10-16, 2021, there were one individual session provided each week. Additionally, for the week of May 3-9, 2021, there was no documented individual sessions provided.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of OP will retrain all Partial Hospitalization therapists on the timeframe requirements, including the documentation of two-weekly individual counseling sessions. Training will take place on 3/23/22.
Charts will be reviewed by Quality Assurance and the OP Director on a monthly basis starting 3/1/2022 and compliance will be monitored monthly as part of the site Medical Records Committee.
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in three of three applicable client records reviewed.Client #25 was admitted to the residential level of care on April 18, 2021 and was discharged on May 4, 2021. The client record did not document follow-up information at the time of the inspection.Client #26 was admitted to the residential level of care on December 3, 2020 and was discharged on January 2, 2021. The client record did not document follow-up information at the time of the inspection.Client #27 was admitted to the residential level of care on February 28, 2021 and was discharged on March 20, 2021. The client record did not document follow-up information at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective, 2/5/22, all patients with a consent to contact for follow up on file will be sent a follow up letter within 5 calendar days of discharge from an RCA inpatient facility. The letter will be mailed to the patient in an unmarked envelope to the address saved in the client record. A batch report will containing a patient specific copy of the Follow up Letter with the patient's address of record printed on the opposite side will be run twice per week to capture all discharged patients within 5 days of discharge. This report will only create letters for patients for whom there is a "Consent to Contact for Follow Up" on file. Designated corporate staff will ensure the printed letters are sent in unmarked envelopes. A report run in Avatar will provide a consolidated list of all printed and sent letters and will be accessible at any time.
Charts will be reviewed by Quality Assurance and the OP Director on a monthly basis starting 3/1/2022 and compliance will be monitored monthly as part of the site Medical Records Committee.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in four of seven applicable client records reviewed. Client #9 was admitted into the outpatient level of care on January 21, 2021 and was active at the time of inspection. A treatment plan update was completed on March 18, 2021 and the next update was due no later than May 18, 2021. However, the update was not completed until June 1, 2021. Additionally, the next treatment plan update was due no later than August 1, 2021. However, the update was not completed until August 24, 2021.Client #12 was admitted into the outpatient level of care on March 4, 2021 and was discharged on June 23, 2021. The comprehensive treatment plan was completed on March 4, 2021 and the first update was due no later than May 4, 2021. However, the update was not completed until June 6, 2021.Client #14 was admitted into the outpatient level of care on March 1, 2021 and was discharged on November 22, 2021. A treatment plan update was completed on June 19, 2021 and the next update was due no later than August 19, 2021. However, the update was not completed until September 29, 2021.Client #15 was admitted into the outpatient level of care on December 30, 2020 and was on discharged May 1, 2021. The comprehensive treatment plan was completed on December 30, 2020 and the first update was due no later than February 1, 2021. However, the update was not completed until May 1, 2021.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
OP Director will conduct a group supervision surrounding treatment plans and timeliness of required documentation. The first supervision took place on 2/25/2022 and follow up will continue quarterly for the next year. OP Director will also hold a monthly refresher training at the all-staff meeting taking place 3/2/2022.
Charts will be reviewed by Quality Assurance and the OP Director on a monthly basis starting 3/1/2022 and compliance will be monitored monthly as part of the site Medical Records Committee.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in one of one applicable records reviewed. Client #15 was admitted to the outpatient level of care on December 30, 2020 and was discharged on May 1, 2021. The client record did not document follow-up information at the time of the inspection. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 2/5/22, all patients with a consent to contact for follow up on file will be sent a follow up letter within 5 calendar days of discharge from an RCA inpatient facility. The letter will be mailed to the patient in an unmarked envelope to the address saved in the client record. A batch report containing a patient specific copy of the Follow up Letter with the patient's address of record printed on the opposite side will be run twice per week to capture all discharged patients within 5 days of discharge. This report will only create letters for patients for whom there is a "Consent to Contact for Follow Up" on file. Designated corporate staff will ensure the printed letters are sent in unmarked envelopes. A report run in Avatar will provide a consolidated list of all printed and sent letters and will be accessible at any time.
Charts will be reviewed by Quality Assurance and the OP Director on a monthly basis starting 3/1/2022 and compliance will be monitored monthly as part of the site Medical Records Committee.
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