INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring inspection conducted on April 9, 2024 through April 11, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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. 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 ensure the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client #29 was admitted to the outpatient level of care on January 8, 2024 and was involuntarily discharged on February 19, 2024. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
This is a repeat citation from the February 2, 2022 and May 4, 2023 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5/1/24, Site Outpatient Director retrained all clinical staff on the Administrative Discharge Appeal Form. Outpatient clinical staff will sign attestations for review of Administrative - Involuntary Discharge Policy. Site Outpatient Director and Corporate Director of Outpatient will continue to provide education via weekly treatment teams meeting (recurring every Tuesday) and supervision regarding utilization of the AD Appeal Form to ensure client was notified, in writing, of the facility's decision to involuntary terminate the client's treatment at the project. Effective 5/2/24, (following re-training on 5/1/24), clinicians will notify Site Outpatient Director of any cases warranting an Involuntary Discharge. Site Director of Outpatient will notify site CEO and Corporate Director of Outpatient for consultation pertaining to Involuntary Discharges. Site Director of Outpatient will provide education on use of AD Appeal Form in live time to ensure completion. QA and Site Director of Outpatient will audit AD Discharges and review in monthly Medical Records Committee meetings. Audits of Administrative Discharges will discontinue after 90 days 90% compliance. |
709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department, within 3 business days, following the death or serious injury of a client due to trauma, suicide, medication error or unusual circumstances.
The facility was notified of the offsite death of a client on June 18, 2023 and the offsite death of another client on December 11, 2023; however, both deaths were not reported to the Department within the required 3 business days.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
For more efficient reporting of Unusual Incidents, RCA-Devon began using the DDAP portal effective 5/7/24. QAPI Specialist to conduct weekly review of the incident reports submissions via the DDAP portal to confirm that Unusual Incidents were reported to the State. This will be monitored via monthly Safety Committee meeting. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for maintenance or detoxification treatment in four of twelve applicable patient records reviewed.
Patient # 1 was admitted to the inpatient non-hospital detoxification activity on April 7, 2024 and was still active at the time of the inspection. The patient was first administered medication on April 8, 2024; however, the informed, voluntary, written consent was signed by the patient on April 9, 2024.
Patient # 2 was admitted to the inpatient non-hospital detoxification activity on April 4, 2024 and was still active at the time of the inspection. The patient was first administered medication on April 5, 2024; however, the informed, voluntary, written consent was signed by the patient on April 7, 2024.
Patient # 4 was admitted to the inpatient non-hospital detoxification activity on April 2, 2024 and was discharged on April 10, 2024. The patient was first administered medication on April 3, 2024; however, the informed, voluntary, written consent was signed by the patient on April 4, 2024.
Patient # 9 was admitted to the inpatient non-hospital activity on April 6, 2024 and was still active at the time of the inspection. The patient was first administered medication on April 7, 2024; however, the informed, voluntary, written consent was signed by the patient on April 9, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 4/24/24, the Consent to Treatment with an Approved Narcotic Drug was added to the Nursing Admission Consent Checklist in Avatar. Site Director of Nursing (DON) is conducting daily audits specific to Narcotic Consents for all new admissions. Site DON and QA will audit 10 charts at random monthly in addition to daily audits, and report on data during monthly Medical Record Committee meetings. Monthly audits specific to Narcotic Consents will discontinue after 90 days 100% compliance. DON sent attestation form on 4/11/24 to all nursing staff. By of 5/8/24, all nursing staff will have signed the Narcotic Informed Consent attestation understanding the regulation for Narcotic Consents per regulation 715.12. |
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
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in three of four applicable client records reviewed.
Client #22 was admitted into the outpatient level of care on September 8, 2023 and was still active at the time of inspection. A treatment plan update was completed on January 4, 2024 and the next update was due no later than March 4, 2024; however, the update was not completed at the time of inspection.
Client #27 was admitted into the outpatient level of care on November 2, 2023 and was active at the time of inspection. A treatment plan update was completed on January 10, 2024 and the next update was due no later than March 10, 2024; however, the update was not completed at the time of inspection.
Client #28 was admitted into the outpatient level of care on September 4 2023 and was active at the time of inspection. A treatment plan update was completed on December 29, 2023 and the next update was due no later than February 29, 2024; however, the update was completed on March 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 4/30/24, all Outpatient clinical staff will have received re-training by Site Director of Outpatient, Site Trainer, and Corporate Director of Outpatient pertaining to successful completion of Treatment Plan Updates. All staff that attended training were required to sign-in to demonstrate presence. Effective 5/7/24, Site Director of Outpatient will utilize the Devon OP Clinical Census Report to review all Treatment Plan Update due dates and upcoming during weekly Tuesday all staff meeting. For 30 days, Site Director of Outpatient, Corporate Director of Outpatient, and QA will audit each week's treatment plan updates to ensure timely completion. 10 charts will be audited monthly to ensure timely completion of treatment plan updates with a goal of 90% compliance in 90 days. Monthly audits on Treatment Planning will continue due to state timeframe expectations. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for notifying the client, in writing, of a decision to involuntarily terminate the client's treatment at the project was submitted and approved by the Department for the May 4, 2023 and February 2, 2022 licensing inspections, and the October 20, 2022 complaint investigation. Notifying the client, in writing, of a decision to involuntarily terminate the client's treatment at the project was again found to be a deficiency in the April 9, 2024 through April 11, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 5/7/24, both inpatient and outpatient will utilize an Administrative Discharge Checklist that demonstrates clinical determination of a decision to involuntary terminate a client's involvement in the program, discussion held with site director and clinical team, resources and referrals provided, and appeal form completed. The checklist forms will be turned into QAPI Specialist for each Administrative Discharge case. QAPI specialist will add AD Appeal form audits to monthly Medical Records committee for review. Effective 5/22/24, Plan of Corrections for regulatory bodies will be included to monthly Medical Records and QAPI meeting to review with leadership on a monthly cadence. The Medical Records and QAPI agenda will include any status updates of current plans of correction, progress of plans, and areas needing improvement. This will remain on the meeting agenda for leadership to review and update monthly. |