INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring inspection conducted on May 6, 2019 through May 8, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to ensure that all heaters were permanently mounted/installed as there was a space heater discovered in counselor office #A714, based on the physical plant inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 5/7,
the heater was removed from the facility. Moving forward, executive director along with facilities and housekeeping will be responsible for daily monitoring of the offices to ensure there are no portable heaters. If a heater is found, housekeeping and/or facilities will report their finding to the executive director. Additionally, monitoring will be conducted monthly during the environment of care walk through. Safety Committee will also support the executive director with regular monitoring.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to conduct an overnight fire drill at least once every 6 months. The facility did conduct an overnight drill on April 16, 2019; however, the last overnight drill prior to that was conducted on May 10, 2018. This was discovered during the review of the May 2018 through April 2019 fire drill logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/7, Executive Director and a Facilities Technician trained the facilities staff on this regulation. Facilities will conduct at least one fire drill during sleeping hours every 6 months. Executive Director will be responsible for scheduling the drills and monitoring the documentation immediately following the drill. Documentation will placed in the fire safety log. Executive Director will be responsible for monitoring the fire safety log monthly. Safety committee, QA Strategist and QAPI Committee will support the Executive Director with monitoring during the monthly Safety Committee Meeting and QAPI Meeting. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to provide documentation that the project director had annually updated and signed the written policy and procedure manual for the current year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/6
QA Strategist updated the policies and procedure manual with the Project Director's signature. Moving forward it will be the responsibility of the QA Strategist to ensure the documentation is included. QA Strategist and QAPI Committee will monitor this annually.
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to ensure that all client records were kept in locked storage containers as there was client-identifying information left unsecured in an unoccupied admissions office, which was discovered during the physical plant inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 5/7, the Admission Director's office was cleared of patient information and secured in a filing cabinet. On 5/7, Executive Director re-educated the Admissions staff on securing
client-identifying information when staff are not in the office. On 6/4, Executive Director will re-train
the Admissions staff on securing patient information. Staff will sign-off on the training. Sign-in sheets will be returned to QA Strategist to ensure all staff were trained. Additionally, Executive Director will be responsible for supplying locked storage containers to staff that require them. Executive Director and QA Strategist will monitor staff areas daily and monthly during the environment of care walkthrough to ensure patient information is secured. The findings will be documented and reported to Project Director and/or staff supervisor.
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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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 1 of 26 client records reviewed.
Client #4 was admitted into the detox level of care on August 31, 2018 and was discharged on September 4, 2018. There was docuementation that billing was made for the treatment episode; however, there was no consent to release information form documented in the record prior to the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 5/7, Executive Director re-educated Admission staff on obtaining an informed and voluntary consent to release information for every patient. On 6/4, Executive Director will re-train the Admissions staff on
on obtaining an informed and voluntary consent to release information for every patient. Admissions staff will sign-off on the training. Sign-in sheets will be returned to QA Strategist to ensure all staff were trained. Monitoring will be conducted by Executive Director and/or Clinical Supervisors during monthly chart audits. Findings will be reported to QA Strategist who will then report to Project Director.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to document the name of the person, agency, or organization to whom disclosure was to be made to on a consent to release information form in 1 of 26 client records reviewed.
Client #1 was admitted into the detox level of care on May 1, 2019 and was still active at the time of the inspection. The release of information form, with a purpose of emergency contact, was signed and dated by the client on May 1, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 5/29, Clinical Director will re-train clinicians, case managers and clinical supervisors during treatment team and in clinical supervision on the disclosure of information consent and what information must be included before the release of information. Staff will sign-off on the training. Sign-in sheets will be returned to QA Strategist to ensure all staff were re-trained. On 5/7, Executive Director re-educated admissions staff on the disclosure of information consent and the information that must be included before release of information. On 6/4, Executive Director will re-train
the Admissions staff on the disclosure of information consent and the information that must be included before release of information.
Admissions staff will sign-off on the training. Sign-in sheets will be returned to QA Strategist to ensure all staff were trained. On-going monitoring will be conducted through monthly chart audits by the Executive Director and/or Clinical Supervisors. The findings will be reported to QA Strategist who will report to Project Director.
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to provide, in the facility's current policy and procedure manual, a specific policy and procedure documenting that the clients have the right to inspect their own records, as well as one of the three directors can temporarily remove portions and the reasons for removal have to be documented in the client record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/31,the suggested updates to the policy will be submitted to RCA corporate policy and procedure committee for approval by the QA Strategist. QA Strategist will be responsible for updating the policy and procedure manual once the policy has been approved and updated. On-going monitoring and updates to the policy and procedure manual will be conducted by QA Strategist when a new policy or procedure has been updated.
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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
The facility failed to provide, in the facility's current policy and procedure manual, a specific policy documenting when/if a client can self-administer medication while in treatment.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/31, suggested updates to the policy and procedure will be submitted to RCA corporate policy and procedure committee for approval by the QA Strategist. QA Strategist will be responsible for updating the policy and procedure manual once the policy has been approved and updated. On-going monitoring and updates to the policy and procedure manual will be conducted by QA Strategist when updated. |
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
The facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in one of one applicable record reviewed.
Client #11 was admitted into the residential level of care on January 12, 2019 and was administratively discharged on January 19, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/4, Clinical Director will develop a written document to notify a patient of RCA's decision to involuntarily terminate the treatment project and for what reason. Clinical Director and Clinical Supervisors will be responsible for training the clinical staff immediately following the creation of the document. Staff will sign-off on the training. Sign-in sheets will be returned to QA Strategist to ensure all appropriate staff were trained. Clinical supervisors will be responsible for monitoring this monthly through chart audits. Findings will be reported to Clinical Director and QA Strategist.
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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
The facility failed to provide the client an opportunity to request the reconsideration of the facility's decision to involuntarily terminate the client in one of one applicable record reviewed.
Client #11 was admitted into the residential level of care on January 12, 2019 and was administratively discharged on January 19, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 6/4, Clinical Director will develop a written document to notify a patient of RCA's decision to involuntarily terminate the treatment project and for what reason. Additionally, the document will written to include the process in which a patient can request a reconsideration of the decision. Clinical Director and Clinical Supervisors will be responsible for training clinical staff on this document immediately following the creation. Staff will sign-off on the training. Sign-in sheets will be returned to QA Strategist to ensure all appropriate staff were trained. Clinical Supervisors will be responsible for monitoring through monthly chart audits. Findings will be reported to Clinical Director and QA Strategist
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715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
The facility failed to provide, in the client record, documentation of how the facility verified the correct identity of the patient prior to the administration of a narcotic agent in one of four applicable records reviewed.
Client #3 was admitted into the detox level of care on May 3, 2019 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 5/7, Executive Director re-educated Admissions staff to require identification of any patient admitting to treatment. On 6/4, Executive Director will re-train the Admissions staff to require identification of any patient admitting to treatment. The identification will then be scanned into Avatar. Admissions staff will sign-off on the training. Sign-in sheets will be returned to QA Strategist to ensure all staff were trained. On-going monitoring will be conducted through monthly chart audits by the Executive Director. The findings will be reported to QA Strategist.
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