INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted November 1, 2023, by staff from the Bureau of Program Licensure. 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.
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Plan of Correction
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on an inspection of bathrooms during a complaint investigation conducted on November 1, 2023, the facility failed to ensure that all bathrooms are ventilated by an exhaust fan or window.
The bathrooms in client bedrooms E-347 and E-354 did not have working ventilation at the time of the investigation.
This was discussed with facility staff at the time of the investigation.
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Plan of Correction
The inactive ventilation system was reactivated on 11/1/23 after being discovered on the day of visit. The Facilities Manager is auditing the ventilation system weekly through a remote HVAC program to check the status of ventilation systems. Facilities technicians audit patient bedrooms daily to report any malfunctions or inactive systems to the Facilities Manager. For 90 days, the Facilities Manager will maintain a log of weekly room audits and will include vent functionality on monthly Environment of Care walkthrough checklist. |
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 a client chart during a complaint investigation conducted on November 1, 2023, the facility failed to ensure a complete client record to include a discharge summary.
Client #1 was admitted to detoxification services on May 5, 2023, stepped down to inpatient rehabilitation and treatment services on May 12, 2023, and was discharged on May 15, 2023. The discharge summary was missing from the client chart at the time of the investigation.
This was discussed with facility staff at the time of the investigation.
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Plan of Correction
As of 6/30/23 all clinical staff were retrained on documentation of discharge summaries in the client record within the required timeframe and signed off on the training. The Clinical Director reviews the Devon Discharge Summary Deficiency Report daily to review past due discharge summaries, discharge summaries due in two days, discharge summaries due in three days, and coming due discharge summaries. This report is sent out daily to the clinical teams to ensure timely documentation. During weekly supervision, the Clinical Director reviews discharge summaries with Clinical Supervisors to review upcoming summaries required. During monthly medical records committee meetings, Quality Assurance audits 10 charts and reports on completed discharge summaries within the required timeframe.
The discharge summary completion percentage is currently at 80%. The plan of correction will discontinue after 90 days with a trend of 90% completion for three consecutive months. |