INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 27-28, 2021 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
Quality Assurance Strategist, Facilities, and IT Analyst will work to ensure that the cameras in the designated client group rooms be disconnected by 11.30.21 to ensure privacy during counseling sessions.
The CEO of RCA-Monroeville has filed a Letter of Exception to Pennsylvania Department of Drug and Alcohol Programs Secretary requesting an exception to video monitoring be allowed within the group rooms for the health and safety of all patients and staff. The letter was sent via certified mailed on 11/29/21.
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
VP of Facilities and Facility Manager contacted vending company on 10.28.21, notifying them that individual paper towels are needed in each of the patients' rooms. Paper towel supplies were delivered on 10.30.21 and distributed into all patient rooms on 10.30.21.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. Suite 1049's hot water was recorded at 134.2.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction 705.6(3):
Facility Manager will work with maintenance staff to adjust and maintain the hot water temperature to be at or below the 120F threshold. Hot water temperature will be reviewed and monitored by Maintenance Staff and presented during monthly Patient Safety Committee.
On 10.28.21, Facility Manager adjusted the hot water temperature to below 120F.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure two employees received the required training in the use of the fire extinguishers upon employment. Employee #8 was hired on May 10, 2021 for the position of counselor and was still employed at the time of the inspection. She did not have the training until May 19, 2021.Employee #9 was hired on June 7, 2021 for the position of counselor and was still employed at the time of the inspection. He did not have the training until June 23, 2021.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction 705(c)(4):
HR and Corporate Trainer will work to ensure that all newly hired staff be trained on fire extinguisher within 7-days upon employment. Effective 11.29.21, weekly orientation will occur for all new hires.
This will be monitored monthly during the Quality Assurance Performance Improvement Committee.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure two employees received the required training to perform assigned tasks during emergencies. Employee #1 was hired on January 31, 2021 for the position of Project Director and was still employed at the time of the inspection. No training was documented.Employee #2 was hired on December 1, 2020 for the position of Facility Director and was still employed at the time of the inspection. No training was documented. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction 705.10(d)(3):
Corporate Director of Training and Corporate Trainer will meet with both employees and review the RCA-Monroeville location as it pertains to fire safety. Employee #1 was provided fire safety training on 11.24.21. Employee #2 was provided facility emergency and fire safety training on 11.15.21.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from March 15, 2021 through September 30, 2021, the facility failed to conduct a fire drill during sleeping hours at least every six months.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction 705.10(d)(5):
Facilities Manager and Quality Assurance Strategist will work to ensure that a fire drill be conducted during sleeping hours from 11pm to 6am, at least every six months. A fire drill during sleeping hours was completed on 11/30/21 at 5:30am.
Fire drills will be monitored by Facility Manager and Quality Assurance as part of monthly Patient Safety Committee held by the 28th of each month.
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709.28(c)(4) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(4) Dated signature of client or guardian.
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in four out of seventeen client records reviewed.Client #1 was admitted on May 16, 2021 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated July 29, 2021 for a healthcare facility, however the client did not sign the informed and voluntary consent. The facility contacted the healthcare facility on July 29, 2021. Client #3 was admitted on July 12, 2021 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated August 13, 2021 for a health facility, however the client did not sign the informed and voluntary consent. The facility contacted the mental health facility on August 13, 2021. Client #4 was admitted on September 14, 2021 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated September 24, 2021 for a primary care physician, however the client did not sign the informed and voluntary consent. The facility contacted the primary care physician on September 24, 2021. Client # 9 was admitted on May 12. 2021 and was discharged on August 5, 2021. A consent to release information was signed by a witness dated May 19, 2021 for the funding source, however the client did not sign the informed and voluntary consent. The facility confirmed that the funding source was billed for services. A consent to release information was signed by a witness dated June 4, 2021 for a legal agency and a telephone call was made to that agency on June 10, 2021.These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
Plan of Correction 709.28:
EMR, Operations, Regional Director will work to ensure Project Docusign for digital signatures is implemented by 12.31.21 to improve upon documentation of informed and voluntary consent with dated signature in client records. Training on the electronic system was held on 11.22.21, 11.23.21 and 11.29.21. Voluntary consent in client record will be monitored by both Site leadership and Quality Assurance as part of monthly Medical Records Committee meetings held once a month. If consents are unable to get completed by clients then this will be documented within medical record by clinical staff.
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709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to include written documentation of proposed type of support service in seven out of seven records.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction 709.52:
The EMR and Operations team has enabled the 'Support Service' test box within client's individual treatment plan, it is also now a required text field ? effective date 11.15.21. Compliance will be monitored daily by site leadership prior to treatment plan submission. Quality Assurance will monitor monthly compliance during medical records committee held by the 28th of each month.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to include written documentation of proposed type of support service in seven out of seven records.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction 709.92:
Clinical Supervisor will work with Clinical Team to ensure that outside patient supportive services are documented in the Medical Record. Clinical Supervisor provided Clinical Team education on 11.5.21, with full implementation by 11.30.21 to improve patient outcome.
Supportive Services will be monitored by Site Leadership and Quality Assurance as part of monthly Medical Records Committee held by the 28th of each month.
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