INITIAL COMMENTS
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This report is a result of an complaint investigation conducted on 7/8/22 by staff from the Bureau of Program Licensure. Based on the findings of the complaint investigation, 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
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Plan of Correction
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a notification of an unusual incident that occurred on 2/4/2020 the facility failed to notify DDAP within the required timeframe of an incident with negative community reaction.The finding was discussed with facility staff do the investigation.
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Plan of Correction
On 7/21/2022, RCA Corporate Risk Analyst/Incident Technician, RCA Devon site Leadership and the Devon Human Resources department were educated on 715.28 (c)(4). Specifically, the expectation that unusual incidents be reported to the Department of Drug & Alcohol Programs within 48 hours following an unusual incident involving:
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
Moving forward, the site will submit an internal Incident Report for any unusual incident within 24 hours per company policy. Doing so will alert the Corporate Risk Analyst/Incident Technician to file an unusual incident report with the Department of Drug & Alcohol Programs within the 48-hour deadline. Site leadership met with their respective departments on 7/25/22 and communicated the expectation of filing incident reports in a timely fashion. This will also be communicated bi-weekly in orientation classes during Incident Report Training for all new hires effective 7/25/22.
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