INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone / buprenorphine monitoring inspection conducted on April 6-7, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Recovery Centers of America at Monroeville 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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709.33 (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
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in three of three applicable client records.
There was no documentation in the following client records to verify that an involuntary termination letter was provided to the clients.
Client #19 was admitted to detoxification level of care September 18, 2025 and involuntarily discharged September 22, 2025.
Client #24 was admitted to residential level of care August 27, 2025 and involuntarily discharged September 18, 2025.
Client #29 was admitted to residential level of care January 31, 2026 and involuntarily discharged February 16, 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
- RCA at Monroeville Clinical Director conducted a training session on 4/8/26 with Senior Leadership Team regarding documentation of the Administrative Discharge Patient Appeal form that will be handed to patient the patient on discharge. A copy of the form will also be scanned into the chart.
- Clinical Director will conduct a review of all Administrative Discharges and provide a monthly outcomes report to the Medical Records Committee, held monthly.
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715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document what materials were sent to the patient's new treatment facility in one of one applicable records.
Patient #26 was admitted on November 16, 2025 and transferred to another facility on December 8, 2025. The note in client record stated that documentation was sent to the receiving facility but failed to document which material was sent.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
- RCA at Monroeville Director of Admission (DOA) conducted a training session on 4/9/26 with case management staff regarding documenting the transfer material sent to the Methadone Clinic at discharge. DOA will perform a 3-month audit of all patients discharged on Methadone. Documentation of the material sent will include:
1. Admission Date
2. Medical Assessment
3. Biopsychosocial Assessment
4. Dosage Level
5. Urinalysis report(s)
6. Current Status of the Patient
7. ROI
- DOA will provide monthly outcomes of the 3-month audit during the Medical Records Committee, held monthly.
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