INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 29, 2020 through October 30, 2020 and November 2, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1. Based on the findings of Part 2, an abbreviated on-site inspection, Recovery Centers 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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709.34 (c) (5) 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:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
The facility failed to file a written unusual incident report with the Department within three business days following an outbreak of a contagious disease requiring CDC notification.Based on conversations with facility staff and staff from the Department, the Department learned that a staff member had tested positive for COVID-19 on October 31, 2020; however, there was no unusual incident report submitted as of the date of the inspection. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
On 11/6/20, RCA Corporate Risk Analyst/Incident Technician, RCA Devon site Leadership and the Devon Human Resources department were educated on 709.34 (c)(5). Specifically, the expectation that unusual incidents be reported to the Department of Drug & Alcohol Programs within 3 business days following an unusual incident involving: (5) Outbreak of a contagious disease requiring CDC notification. Moving forward, Devon Human Resources 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 a written unusual incident report with the Department of Drug & Alcohol Programs within the 3 business day deadline. Site leadership met with their respective departments on 11/9/20 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 beginning 11/17/20. |
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
The facility failed to ensure that all treatment plans were reviewed and updated at least every 60 days in six of seven out-patient client records reviewed. Client #1 was admitted on April 30, 2020 and was active at the time of inspection. A treatment plan update was completed on August 17, 2020 and the next update was due no later than October 17, 2020. However, the update was not completed at the time of inspection. Client #2 was admitted on August 3, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed on August 3, 2020 and an update was due no later than October 2, 2020. However, the update was not completed at the time of inspection. Client #3 was admitted on January 31,2020 and was active at the time of inspection. A treatment plan update was completed on April 16, 2020 and the next update was due no later than June 16, 2020. However, the update was not completed at the time of inspection.Client # 5 was admitted on November 26, 2019 and was discharged May 29, 2020. A treatment plan update was completed on January 8, 2019 and the next update was due no later than March 8, 2020. However, the update was not completed until March 24, 2020. Client # 6 was admitted April 30, 2020 and was discharged October 15, 2020. The comprehensive treatment plan was completed on April 30, 2020 and an update was due no later than June 30, 2020. However, the update was not completed at the time of inspection. Client # 7 was admitted June 13, 2019 and was discharged August 14, 2020. A treatment plan update was completed on January 14, 2020 and the next update was due no later than March 14, 2020. However, the update was not completed at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On the week of 11/9/20, RCA Devon Outpatient site leadership reviewed expectations of meeting treatment plan timeframes during an all staff supervision. Treatment plan training for RCA Devon OP was last completed on 10/21/20 by OP QA due to new 24 hour completion of Master treatment planning requirement per state payor that was revised. During this training, QA reviewed Treatment Plan expectations while including importance of timeliness for initial and updates of treatment plans. OP QA will attend staff meeting on Nov 25th to follow up with staff about meeting 24 hour timeframe and review training material once again to ensure understanding. QA will review new staff changes monthly during Committee meetings which are held third Friday of the each month to ensure new staff are trained up on tx planning. In addition, site will be responsible to continue to make use of treatment plan compliance report that is sent out daily. This will allow staff to manage/monitor initial tx plan and updates ongoing per state timeframes. This resource will be reviewed weekly to ensure compliance and to discuss any barriers. State time frames are reviewed at least once monthly during Medical Records Committee and updated as needed during staff supervision, trainings, and biweekly calls with leadership per 31 Pa. Code § 89.623 (Chapter 711 standards for PHP and Outpatient services). RCA OP services will continue to help staff to meet this requirements in timely fashion. |
709.93(a) 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:
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Observations
The facility failed to ensure there was a complete client record documented. which is to include aftercare plans, in three of four applicable client records reviewed.Client # 4 was admitted on December 10, 2019 and was discharged April 7, 2020. The facility failed to document an aftercare plan documented in the client record.Client # 5 was admitted on November 26, 2019 and was discharged May 29, 2020. The facility failed to document an aftercare plan documented in the client record.Client # 7 was admitted June 13, 2019 and was discharged August 14, 2020. The facility failed to document an aftercare plan documented in the client record.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
On 12/16/20, OP QA will conduct a training surrounding Coordination of Care (OP process)/Continuum of Care (IP) and discharge summary expectations during the discharge process. The training material will be based off of RCA Policy referencing Case Management for clinical staff in all RCA programs as well as policy pertaining to timeframes for document completion and discharge process. QA has a plan to also revise company policy surrounding aftercare geared towards OP participants with expected completion by 12/31/20. QA and IT team are working on creating a Discharge Report that will capture deficient areas in regards to discharge planning and discharge summary compliance. Lastly, Medical Record committees will continue to be held by 28th of each month to review chart deficiencies in hopes of preventing citation in this area for the future. |