INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on August 28, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site 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.
|
Plan of Correction
|
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
The facility failed to adhere to procedures for the management of client belongings at the time of admission. The facility's "Admission Process" policy states that "valuables will be collected from the patient and logged and bagged-phone, wallet (each bill and coin accounted for...)
A client was admitted to the facility on 06/04/19, the facility did not log the amount of currency that the client brought into the facility until 06/06/19. In addition, each coin and bill was not logged. Finally, the client's wallet was not logged at the time of admission and there was no documentation to verify that the client's wallet had been returned at the time of discharge.
|
Plan of Correction
1. On 10/22/19, Admission's Coordinators will be re-educated and re-trained in the admission process as it relates to the collection and documentation of valuables. They will be required to count coins and each bill in the presence of the patient and witness and document correctly.
Re-education will be completed by the Facility Trainer and Director of Admissions.
2. On 10/16/19, QA Strategist, RSS Supervisor and Executive Director created an Admission Process quick reference guide. The reference guide will be laminated and posted in every exam room in the admissions area on 10/22/19.
3. On 10/1/19, the discharge process was updated to include:
a. A discharge coordinator who will meet with every discharging patient.
b. Valuables will be checked 24 hours prior to discharge by the clinical coordinator and/or house supervisor.
c. Day of discharge, valuables will be checked again and itemized with the discharge coordinator and discharging patient. All items will be bagged and sealed and signed for by the patient. The items will remain in a locked cart until the patient is ready for transport.
Completion Date:
1. 10/22/19. Admissions Director will be responsible for ongoing monitoring. As a result of the new discharge process, the valuable sheets are audited daily (24 hours before discharge and on the day of discharge). Discharge Coordinator will report missing information to the Admission Director. Admission's Director will report findings to Executive Director.
2. 10/16/2019. QA Strategist, Executive Director and RSS Supervisor will be responsible for placing laminated sheet in the exam rooms. QA Strategist and RSS Supervisor will be responsible for updating the reference sheets as needed.
3. The new discharge process was implemented on 10/1/19. Ongoing monitoring will be conducted by Admission's Director and Executive Director. Findings will be reported to the leadership team.
4. The Quality Assurance Strategist, Executive Director and CEO will be responsible for ensuring the corrective action is completed.
|
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on staff interviews and a review of a client record on August 28, 2019, the facility failed to report an incident that occurred on 06/28/19, which required the presence of police personnel.
|
Plan of Correction
1. On 10/28/19, Staff will be re-educated on the requirements to submit an Incident Report for Law Enforcement activity to include non-emergencies.
The Facility Trainer and Quality Assurance Strategist will be responsible for re-educating staff on the requirements for Incident Report completion.
2. QA is responsible for reviewing shift reports and emails daily to ensure incident reports are submitted when applicable.
3. QA Strategist is responsible for reviewing incident reports daily and reporting the findings to the CEO, Executive Director and Clinical Director in our daily flash meeting.
4. QA is responsible for reviewing RCA-ACTS calls which are ideas, complaints, and compliance, legal, or ethical concerns. ACTS does not override the need for an incident report. QA is responsible for investigating the concern and alerting appropriate staff to ensure compliance with regulations.
Completion Date:
1. On 10/28/19, CEO will send an email to all staff reminding them of the requirement to notify QA Strategist and/or CEO of law enforcement activity not limited to emergency situations and the submission of an incident report.
2. QA Strategist conducts Incident Report training every other Tuesday. QA will continue to train on the importance of notifying QA Strategist, Executive Director or CEO of law enforcement activity and incident report submission.
3. The Quality Assurance Strategist, Executive Director and CEO will be responsible for ensuring the corrective action is completed.
|