INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on May 1, 2023, through May 4, 2023, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of 30 personnel records, the facility failed to provide documentation showing that clinical supervisors had monthly meetings with their supervisors for the first six months of employment in that position, in one record reviewed. Employee #4 was promoted to the position of clinical supervisor on February 12, 2023 and has remained in that position. Supervision was not documented as beginning until April 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director is responsible for completion of supervision with clinical supervisors. Clinical Director will sign attestation of understanding of 704.6(e) by 6/30/2023. Employee #4 received supervision 5/11/23, 5/12/23, 5/16/23, and 5/17/23. Supervision will continue on a monthly basis and be tracked in monthly QAPI committee meetings to ensure ongoing compliance. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level that documented it was developed annually with input from both the employee and the supervisor in two out of thirty personnel records reviewed.Employee #8 was hired as a counselor on December 12, 2022. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed. Employee #28 was hired as a counselor on September 20, 2021. The individual training plan had no documentation that the plan was developed with input from both the employee and supervisor and the date completed. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Training Department will track training hours for each staff member. Employee #8 and supervisor will sign individual training plan by 6/30/2023. Employee #28 is no longer employed with RCA.
The Training Department will establish by 6/30/23 annual training plans within the electronic training system Relias that will include employee and supervisor signatures that are date and time stamped. The Training Department will train all supervisors on this new process by 7/15/2023. All supervisors will sign off on the training. A quarterly compliance report will be added to the QAPI meeting agendas to track signature completion. The Site Trainer will be responsible for ensuring this plan is implemented.
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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 30 personnel records, the facility failed to ensure that staff received at least 6 hours of HIV/AIDS and 4 hours of TB/STD training within one year in one record reviewed.Employee # 29 was hired by the facility on September 7, 2021 as a counselor and has remained in the same position. The employee was due to have the HIV/AIDS and TB/STD trainings no later than September 7, 2022; however, they were not completed until September 13, 2022 and October 27, 2022, respectively. This is a repeat citation from the February 2, 2022 and May 1, 2020 annual licensing inspections. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A tracking system is in place to monitor and notify staff members of their need to complete the Communicable Disease training in required timeframes. This system allows 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. All supervisors will receive reeducation on this process and sign off on it by 6/30/2023. The Training Department will manage the tracking and scheduling of the Communicable Disease trainings. HIV/AIDS training is now available online. The site trainer will be trained on conducting the TB/STD training by 6/30/2023. Both the HIV/AIDS and TB/STD trainings will be added to orientation training for all new hires beginning 6/30/2023 to ensure all staff receive these trainings within the required timeframes. Training Department will provide QA with quarterly update on employees upcoming or overdue training due dates which will be reviewed in QAPI committee meetings. The Site Trainer will be responsible for ensuring this plan is implemented.
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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 document the completion of 25 clock hours of annual training required for counselors in one of two applicable records.Employee # 29 was hired as a counselor on September 7, 2021 and has remained in that position. The facility's training year that was reviewed was from January 2022 through December 2022. Employee #29's personnel record only documented 14.5 hours of training for the period reviewed.This is a repeat citation from the February 2, 2022 and May 1, 2020 annual licensing inspections. These findings were 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. Clinical Supervisors will be notified quarterly of status of annual clinical hours needed. Clinical Director and Clinical Supervisors will be responsible for ensuring staff completing training hours and/or will establish a date and time for them to complete their training hours. Additionally, this will be reported on quarterly within the QAPI committee meetings. |
704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1. Employee #29 was hired as a counselor on September 7, 2021 and has remained in that position. Employee #29 was reported to have 40 hours per week devoted to their 38 clients on their caseload.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.The FTE counselor ' s caseload calculation is as follows: 40/40 = 1(FTE); 38/1 = 38, which equals to a client/counselor ratio of 38:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
QA and OP Director will sign attestation for understanding FTE counselor caseload calculation by 6/30/2023. Additional clinical staff has been added to support the site. The OP Director is reviewing individual therapist caseloads daily to ensure compliance and adjusting as necessary. |
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
The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room, as a group session in room E327 could be seen outside of the group room through the glass door at 10:00 a.m. on May 3, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Statement of communication to all site staff was circulated on 6/9/2023 on privacy of clinical sessions and that blinds must be drawn on all windows and doors so that counseling sessions cannot be seen outside the counseling room. QA will conduct weekly walkthroughs and note compliance on EOC document submitted monthly. For any occurrence of noncompliance, QA will notify Clinical Director and RSS Supervisor for prompt correction. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on May 3, 2023, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom as neither were in any client bathroom. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
House Keeping ordered boxes of disposable hand towels. These will be distributed to patient rooms on active units by 6/15/2023. House Keeping staff cleans patient bedroom bathrooms daily during which they will check and replenish disposable hand towels as needed. |
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 27 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information prior to disclosing information in two records reviewed. Client #2 was admitted to the detox level of care on March 19, 2022 and discharged on March 26, 2022. The record contained documentation of contact with a family member on March 22, 2022, to whom the record contained no informed and voluntary consent to release information form signed by the client.Client #10 was admitted to the rehabilitation level of care on May 6, 2022 and discharged on May 16, 2022. The record contained documentation of contact with an attorney on May 9, 2022; however, the informed and voluntary consent to release information form was not signed by the client until May 11, 2022.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Site Trainer will retrain all clinical staff on consents by 6/30/23 and obtain staff signatures. Clinical Director and Clinical Supervisors will continue providing education via treatment teams and supervision regarding obtaining and reviewing consents prior to making any contact calls. Completion of this plan will be responsibility of QA and Clinical Director. Completion and compliance with consents will be monitored by QA and Clinical Director via auditing 10 charts and reviewing in monthly Medical Records Committee meetings. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of 27 client records, the facility failed to ensure that informed and voluntary consent to release information forms included the signature of the client in 4 records reviewed.Client #16 was admitted to the partial hospitalization level of care on October 31, 2022 and discharged on November 11, 2022. The record contained a consent to release information form to the funding source dated October 31, 2022, that was missing the signature of the client. The facility acknowledged billing was occurring. Client #22 was admitted to the outpatient level of care on November 11, 2022 and discharged on January 19, 2023. The record contained a consent to release information form to the funding source dated October 31, 2022, that was missing the signature of the client. The facility acknowledged billing was occurring.Client #25 was admitted to the outpatient level of care on January 12, 2023 and was active at the time of the inspection. The record contained a consent to release information form to the funding source dated January 30, 2023, that was missing the signature of the client. The facility acknowledged billing was occurring.Client #26 was admitted to the outpatient level of care on April 4, 2022 and was discharged on September 30, 2022. The record contained a consent to release information form to the funding source dated April 4, 2022, that was missing the signature of the client. The facility acknowledged billing was occurring.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Completion of and obtaining of signature for the funding source is the responsibility of clinical staff. The funding source consent is signed during all in-person assessments. A new process of obtaining signatures from clients completing their initial assessment via Telehealth was implemented 2/21/2023. Consents for Assignment of Benefits are now being sent directly to the client via EMR system AVATAR to obtain signature. OP Director and QA are responsible for conducting audits of 10 charts for completion to be reviewed in monthly Medical Records Committee. OP Director will have clinical staff sign attestation on understanding the process by 6/30/23. Clients 16, 22, and 26 were discharged at the time of survey. Client #25 will sign a consent for the funding source by 6/30/2023. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of medication administration records and client records, the facility failed to have a data collection and recordkeeping system that allowed for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.A request was made for information identifying whether a client was administered narcotic treatment medications from the facility ' s stock supply or pharmacy supply, the facility's recordkeeping system did not allow for the identification of the information prior to the conclusion of the onsite inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Site is working with IT Department to create by 6/30/2023 a method of tracking NTP patients by distinguishing medication ordered from stock or pharmacy supply. Orders will be entered as house stock for taper or MAT until patient specific order is received, the order will be entered as POM. Once approved, all medical and nursing staff will sign off they have received training and education on the process. A monthly report will be generated and 1 chart audited and compared with narcotic book to ensure this process was done correctly. Audits will discontinue after 90% compliance for 90 days. QA, Medical Director, and DON are responsible for ensuring corrective action is implemented. |
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 document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in two of three applicable records reviewed.Client #1 was admitted to the detoxification level of care on March 21, 2022 and was involuntarily discharged on March 22, 2022. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.Client #4 was admitted to the detoxification level of care on February 17, 2023 and was involuntarily discharged on February 20, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.This is a repeat citation from the February 2, 2022 annual licensing inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 6/30/2023, Clinical Director will retrain clinical staff on the Administrative Discharge Appeal Form. Clinical staff will sign attestations for review of Administrative ? Involuntary Discharge Policy. Clinical Director and Clinical Supervisors will continue providing education via treatment teams and supervision regarding utilization of the AD Appeal Form to ensure client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project. Clinical Director and Clinical Supervisors will provide education on use of AD Appeal Form in live time. QA and Clinical Director will audit AD discharges and review in monthly Medical Records Committee meetings. Audits of Administrative Discharges will discontinue after 90 days of 90% compliance. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation information in three of five applicable records reviewed. Client # 15 was admitted on June 24, 2022 and was discharged on July 21, 2022. There was no documentation of a case consultation in the record. Client # 17 was admitted on February 1, 2023 and was discharged on February 14, 2023. There was no documentation of a case consultation in the record.Client # 20 was admitted on March 8, 2023 and was discharged on March 31, 2023. There was no documentation of a case consultation in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
OP Director will retrain all clinical staff on the implementation of case consultations in the client record by 6/30/23 and obtain staff signatures. OP Director and QA will audit 10 charts on a monthly basis to ensure completion of case consultations. This will be reviewed in monthly medical records committee meetings. |
709.83(a)(10) LICENSURE Client records
709.83. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary in one of two applicable records reviewed. Client #18 was admitted to the partial level of care on February 2, 2023 and was discharged on February 14, 2023. There was no documentation of a discharge summary in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will receive retraining by OP Director on the completion of discharge summaries in the client record within the required timeframe by 6/30/2023 and obtain staff signatures. Facility Director and QA will audit 10 charts on a monthly basis to ensure completion of discharge summaries. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary in one of two applicable records reviewed. Client #4 was admitted to the detoxification level of care on February 17, 2023 and was discharged on February 20, 2023. There was no documentation of a discharge summary in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 6/30/23, Clinical Director will retrain staff on documentation of discharge summaries in the client record within the required timeframe.
Signatures from staff trained will be obtained.
Clinical Director and QA will audit 10 charts to ensure completion of discharge summaries, and this will be reviewed in the monthly Medical Records Committee meetings. Clinical Director will monitor the daily Discharge Summary Deficiency Report.
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715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based a review of patient records, the transferring facility failed to document what materials were sent to the receiving facility in one of one applicable record reviewed. Patient #8 was admitted to the rehabilitation level of care on November 18, 2022 and transferred to another narcotic treatment program on December 12, 2022. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing Case Manager received retraining 5/30/23 and signed off on retraining 6/7/23 with DON on documenting what materials were sent to receiving facility. NCM will be sending the DON a weekly spreadsheet of patients discharge with appointments for methadone MAT with patient name, dose, method used to communicate to next facility, and when documented in the patient chart. DON will audit each chart on a weekly basis to ensure documentation was completed. Audits will discontinue after 90 days of 90% compliance. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project including a discharge summary in two of four applicable records reviewed. Client #10 was admitted to the rehabilitation level of care on May 6, 2022 and was discharged on May 16, 2022. There was no documentation of a discharge summary in the record.Client #13 was admitted to the rehabilitation level of care on March 28, 2023 and was discharged on April 20, 2023. There was no documentation of a discharge summary in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will conduct retraining with all clinical staff by 6/30/23 on completion of discharge summaries in the client record within the required timeframe. Staff will sign off on the training. Clinical Director and QA will audit 10 charts to ensure completion of discharge summaries, and this will be discussed in the monthly Medical Records Committee meetings. Clinical Director will do a daily review of Discharge Summary report. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project including case consultation information in three of five applicable records reviewed. Client # 21 was admitted on July 21, 2022 and was discharged on November 28, 2022. There was no documentation of a case consultation in the record. Client # 26 was admitted on April 4, 2022 and was discharged on September 20, 2022. There was no documentation of a case consultation in the record.Client # 27 was admitted on January 23, 2023 and was discharged on April 27, 2023. There was no documentation of a case consultation in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
OP Director will retrain clinical staff on the documentation of case consultations in the client record by 6/30/23 and obtain staff signatures. OP Director and QA will audit 10 charts on a monthly basis to ensure completion of case consultations. This will be reviewed in monthly medical records committee meetings. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project including an aftercare plan in one of two applicable records reviewed. Client #22 was admitted on November 11, 2022 and was discharged on January 19, 2023. There was no documentation of an aftercare plan in the record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
OP Director will retrain the clinical staff on the completion of aftercare plans in the client record by 6/30/23 and obtain staff signatures. OP Director and QA will audit 10 charts on a monthly basis to ensure completion of aftercare plan. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of personnel records and client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for training staff in HIV/AIDS and TB/STD within the regulatory timeframe was submitted and approved by the Department for the February 2, 2022 and May 1, 2020 annual licensing inspections. Training staff in HIV/AIDS and TB/STD within the regulatory timeframe was again found to be a deficiency in the May 1, 2023 through May 4, 2023 licensing inspection.A plan of correction for notifying the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project was submitted and approved by the Department for the February 2, 2022 licensing inspection and October 20, 2022 complaint investigation. Notifying the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project was again found to be a deficiency in the May 1, 2023 through May 4, 2023 licensing inspection.A plan of correction for counselors failing to complete at least 25 clock hours of training annually was submitted and approved by the Department for the February 2, 2022 licensing inspection. Counselors failing to complete at least 25 clock hours of training annually was again found to be a deficiency in the May 1, 2023 through May 4, 2023 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
QA Stategist will monitor implementation and compliance with all POCs and maintain a monthly log documenting compliance. |