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 2-3, 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 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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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the facility failed to document the verbal or telephone medication orders were authenticated in writing by the practitioner in five of nine client records.
In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
Client #1 was admitted to detox treatment on January 27, 2024 and was discharged on February 5, 2024. Two verbal medication orders were documented as given on January 28, 2024 and January 30, 2024. As of the date of the inspection, the written authentication was not documented for either medication order.
Client #2 was admitted to detox treatment on February 17, 2024, and was discharged on February 19, 2024. A verbal medication order was given on February 19, 2024. The written authentication was documented late on March 12, 2024.
Client #3 was admitted to detox treatment on March 4, 2024, and was discharged on March 7, 2024. A verbal medication order was given on March 6, 2024. As of the date of the inspection, the written authentication was not documented.
Client #5 was admitted to residential treatment on January 30, 2024, and was discharged on February 15, 2024. A verbal medication order was given on January 31, 2024. The written authentication was documented late on February 17, 2024.
Client #7 was admitted to detox treatment on February 10, 2024, and was discharged on February 16, 2024. A verbal medication order was given on February 13, 2024. The written authentication was documented late on April 2, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
RCA-Monroeville Medical Director conducted a training and education session on April 9, 2024, with Practitioners regarding Verbal Order verification with 24-hours. This will be monitored via Medical Records Committee, held monthly. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days.
The facility had an unusual incident occur on September 21, 2023, October 13, 2023, October 24, 2023, December 2, 2023, and January 21, 2024 all which involved physical altercations. The facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
For more efficient reporting of unusual incidents, RCA-Monroeville began using the DDAP portal effective March 1, 2024. 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 Safety Committee, held monthly. |
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.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days.
The facility had unusual incidents occur on September 1, 2023, September 22, 2023, October 30, 2023, December 15, 2023, January 21, 2024, February 22, 2024, and February 26, 2024, all which involved events at the facility requiring the presence of police or ambulance. The facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
For more efficient reporting of unusual incidents, RCA-Monroeville began using the DDAP portal effective March 1, 2024. 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 Safety Committee, held monthly. |
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
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days.
The facility had unusual incidents occur on August 25, 2023, August 30, 2023, September 1, 2023, September 6, 2023, September 7, 2023, two incidents on September 9, 2023, September 12, 2023, October 2, 2023, two incidents on October 3, 2023, October 4, 2023, October 6, 2023, October 11, 2023, October 17, 2023, October 20, 2023, October 21, 2023, November 4, 2023, November 11, 2023, three incidents on November 27, 2023, November 30, 2023, December 1, 2023, December 5, 2023, four incidents on December 6, 2023, December 19, 2023, January 8, 2024, January 17, 2024, and February 6, 2024, all which involved outbreaks of a contagious disease requiring CDC notification.
The facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
For more efficient reporting of unusual incidents, RCA-Monroeville began using the DDAP portal effective March 1, 2024. 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 Safety Committee, held monthly. |