INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted August 11, 2022, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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.
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Plan of Correction
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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 complaint investigation conducted on August 11, 2022, the facility failed to submit an Unusual Incident Report as required for a physical assault by staff or a client.
Facility documentation showed that a client participated in a physical altercation during a family visitation day at the facility on July 10, 2022. The facility did not report the incident as required.
This was discussed with facility staff at the time of the investigation.
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Plan of Correction
Quality Assurance Strategist provided additional training on 8/16/2022 to all staff regarding the submission of Unusual Incidents that occur within the facility.
Quality Assurance Strategist has been working in conjunction with Risk Analyst and Incident Technician to provide timely submissions of Incidents within 3 business days of the event.
This will be reviewed and monitored monthly at QAPI
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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 complaint investigation conducted on August 11, 2022, the facility failed to submit an Unusual Incident Report as required for the presence of police, fire or ambulance personnel at the facility.
Facility documentation showed that police and ambulance personnel were on the premises in response to an incident that occurred at the facility on July 10, 2022. The facility did not report the incident as required.
This was discussed with facility staff at the time of the investigation.
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Plan of Correction
Quality Assurance Strategist provided additional training on 8/16/2022 to all staff regarding the submission of Unusual Incidents that occur within the facility.
In addition, Quality Assurance Strategist has been working in conjunction with Risk Analyst and Incident Technician to provide timely submissions of Incidents within 3 business days of the event.
This will be reviewed and monitored monthly at QAPI
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