INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on April 24-26, 2023 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:
|
Plan of Correction
|
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
|
Observations
Based on a review of personnel records, the facility failed to document the facility director met both the educational and experiential qualifications for the position.
Staff #1 was hired as the facility director on December 12, 2022. Staff #1 has a degree in architecture, which does not meet the educational requirement.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
RCA-Monroeville CEO contacted DDAP Licensure Division on April 24, 2023, requesting for Facility and Program Director exemption. On May 12, 2023, RCA-Monroeville CEO received letter of exemption signed by Division of Licensing Operations. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection, the facility failed to prohibit heaters that are not permanently mounted or installed.
A physical plant inspection was conducted on April 25, 2023. A portable heater was observed in room 2064.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facilities removed space heater from patient room 2064 on April 25, 2023.
Quality Assurance Strategist, RSS Supervisor, Director of Nursing, and Facilities conducts Environment of Care (EOC) rounds monthly. Portable heaters are not permitted in the facility and will be removed immediately if observed during safety rounds. EOC rounds will be during Safety Committee, held monthly.
|
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of fire drill logs, the facility failed to document the exit route used and whether the fire alarm or smoke detector was operable for each of the fire drills conducted between April 2022 through April 2023.
The fire drill logs dated September 30, 2022 and April 11, 2023 did not include the exit route used. The fire drill logs dated August 14, 2022 and March 25, 2023 did not include whether the fire alarm or smoke detector was operable.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
RCA Director of Corporate Facilities Audits and Compliance provided a review and education on 6/21/23 with Facilities Tech regarding Fire drill Evaluation Form. Included in the education and review of the Fire Drill Evaluation form exit route used and fire alarm and smoke detector are included in the form and will be filled out moving forward.
This will be monitored via the Safety Committee, held monthly.
|
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on the consents to release information to the funding source in thirteen out of thirteen client records.
Client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 contained signed consents to release information to the funding source that did not include a purpose for the consent.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In addition to an Assignment of Benefits form that is used to release information to insurance, RCA Monroeville uses a form titled "Release of Information to Third Party." The Release of Information form is used for all other releases including emergency contact, primary care provider, family, and any other third party. Both forms include a purpose for release of client-oriented information. The Director of Admissions will train admissions staff on the completion of both forms. Monitoring of form completion will be provided via the Medical Records Committee held monthly. |
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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on a review of client records, the facility failed to document a dated signature of the client on the consents to release information in thirteen of thirteen records.
Client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 contained consents to release information that were signed by the client, but not dated.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the April 15, 2022 and October 28, 2021 annual licensing inspections.
|
Plan of Correction
RCA-Monroeville Director of Admissions conducted a training and education session on May 10, 2023, with Admission Staff regarding consent documentation to include date and signature.
This will be monitored via Medical Records Committee, held monthly.
|
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
|
Observations
Based on a review of client records, the facility failed to document written acknowledgment by the client, of the right of the director to remove portions of the record prior to client inspection if it is determined that the information may be detrimental if presented to the client in thirteen of thirteen client records.
Client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13 did not include written acknowledgement by the client of the right of the director to remove portions of the record prior to client inspection if it is determined that the information may be detrimental if presented to the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
RCA-Monroeville Inpatient Patient Handbook revised by Operations, Medical, Quality Assurance, and Policy and Procedures Committee. Statement was included in the handbook which requires acknowledgement of the right of the Director to remove portions of the record prior to clinical inspection if it is determined that the information may be detrimental if presented to the client. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of applicable client records, the facility failed to document the type and frequency of services on the individual treatment and rehabilitation plan for partial hospitalization clients in five of six client records.
Client #1 was admitted on November 7, 2022 and discharged on January 10, 2023. The type and frequency of services was not clear on the treatment plan in client record #1.
Client #2 was admitted on November 30, 2022 and discharged December 30, 2022. The type and frequency of services was not clear on the treatment plan in client record #2.
Client #3 was admitted on January 17, 2023 and discharged February 21, 2023. The type and frequency of services was not clear on the treatment plan in client record #3.
Client #4 was admitted on February 23, 2023 and discharged February 27, 2023. The type and frequency of services was not clear on the treatment plan in client record #4.
Client #7 was admitted on February 28, 2023 and is currently active. The type and frequency of services was not clear on the treatment plan in client record #7.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
RCA-Monroeville Outpatient Clinical Director conducted a training and education session on 5/3/23 with clinical staff regarding the type and frequency of services in a clear manor in the Treatment Plan. Additionally, completion of patient treatment plans moved from Outpatient Assessors to Primary Therapist.
This will be monitored via Medical Records Committee, held monthly.
|
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on a review of applicable client records, the facility failed to provide at least two individual therapy sessions per week for partial hospitalization clients in five of six client records.
Client #1 was admitted on November 7, 2023 and discharged on January 10, 2023. There was no documentation that two individual therapy sessions per week were provided to client #1.
Client #2 was admitted on November 30, 2022 and discharged on December 30, 2022. There was no documentation that two individual therapy sessions per week were provided to client #2.
Client #3 was admitted on January 17, 2023 and discharged on February 21, 2023. There was no documentation that two individual therapy sessions per week were provided to client #3.
Client #6 was admitted on August 3, 2022 and discharged on October 21, 2022. There was no documentation that two individual therapy sessions per week were provided to client #6.
Client #7 was admitted on February 28, 2023 and is currently active. There was no documentation that two individual therapy sessions per week were provided to client #7.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
RCA-Monroeville Outpatient Clinical Director conducted a training and education with Outpatient clinical staff on May 3, 2023, regarding the completion and documentation of individual counseling services at least twice weekly for Partial Hospitalization Program.
This will be monitored via Outpatient Medical Record Committee, held monthly.
|
709.83(a) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
|
Observations
Based on a review of partial hospitalization client records, the facility failed to maintain a complete client record which includes information relative to the client's involvement with the project.
An electronic client recordkeeping system is currently being utilized; however, not all of the information is contained within that system. A separate recordkeeping system is utilized when a client intake is virtual. This information is to be uploaded to the main system, so the client record is complete. This information was not uploaded for the partial hospitalization clients reviewed; therefore, they are not complete client records.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
RCA-Monroeville utilizes DocuSign program to obtain patient signatures, which is integrated into the patients Electronic Medical Record (EMR). Signed documents are imported from DocuSign into EMR once both parties, patient and staff, signature are complete. Outpatient Clinical Director provided education to staff on 6/21/23. This will be monitored by Outpatient Medical Record Committee, held monthly. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document follow up contact in three of three client records who were discharged from the partial hospitalization activity.
Client #1 was admitted on November 7, 2022 and discharged on January 10, 2023. There was no follow up contact in client record #1.
Client #2 was admitted on November 30, 2022 and discharged on December 30, 2022. There was no follow up contact in client record #2.
Client #3 was admitted on January 17, 2023 and discharged on February 21, 2023. There was no follow up contact in client record #3.
These findings were reviewed with facility staff during the licensing process.
This is a repeat from the April 15, 2022 annual licensing inspection.
|
Plan of Correction
Post-discharge follow-up contact is managed by RCA's Corporate Compliance and Quality Staff. The Director of Risk and Safety was educated by the Senior Director of Compliance and Quality on 6/20/23 on the need to follow up with patients within 5-days of discharge and to document follow-up. Senior Director of Quality and Compliance and Director of Risk and Safety will monitor for completion of follow up contact via outpatient medical records committee meeting. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
|
Observations
Based on a review of patient records, the facility failed to verify the individual has reached 18 years of age in three of three patient records.
Patient records #11, 12 and 13 did not include documentation of patient identification, including date of birth.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
RCA-Monroeville Admissions Director conducted a training and education session on May 10, 2023, with Admission Staff regarding patient ID verification and use of the Identification Attestation form if the patient does not have formal identification.
This will be monitored via Medical Records Committee.
|
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on a review of patient records, the facility failed to verify the patients name, address and date of birth in three of three patient records.
Patient records #11, 12 and 13 did not include documentation of patient identity including the patients name, address and date of birth. The facility procedure is to obtain identification. If no identification is available, an attestation form is completed. There was no completed attestation form documented in patient records #11, 12 and 13.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
RCA-Monroeville Admissions Director conducted a training and education session on May 10, 2023, with Admission Staff regarding patient ID verification and use of the Identification Attestation form if the patient does not have formal identification.
This will be monitored via Medical Records Committee.
|
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
Based on a review of patient records, the facility failed to document a consultation between the CRNP that completed the patient examination and the physician that determined the patient's initial dose and schedule in three of three patient records.
There was no consultation documented between the CRNP and the physician in patient records #11, 12 and 13.
These findings were reviewed with facility staff during the licensing process.
This is a repeat from the April 15, 2022 annual licensing inspection.
|
Plan of Correction
RCA-Monroeville Medical staff has been instructed to document consultation between the CRNP that completed the patient examination and the physician that determined the patient's initial dose and schedule.
This will be monitored and reviewed via Medical Records, held monthly.
|
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
|
Observations
Based on a review of outpatient client records, the facility failed to maintain a complete client record which includes information relative to the client's involvement with the project.
An electronic client recordkeeping system is currently being utilized; however, not all of the information is contained within that system. A separate recordkeeping system is utilized when a client intake is virtual. This information is to be uploaded to the main system, so the client record is complete. This information was not uploaded for the partial hospitalization clients reviewed; therefore, they are not complete client records.
These findings were reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
RCA-Monroeville utilizes DocuSign program to obtain patient signatures, which is integrated into the patients Electronic Medical Record (EMR). Singed documents are imported from DocuSign into EMR once both parties, patient and staff, signature are complete. Outpatient Clinical Director provided education to staff on 6/21/23 regarding DocuSign. This will be monitored by Outpatient Medical Record Committee, held monthly. |
709.15(b) LICENSURE Subchapter B.Licensing Procedures.Right to en
709.15. Right to enter and inspect.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
|
Observations
Based on a review of client/patient records, the facility failed to provide full and free access to the records of the facility and its clients.
The licensing staff were not able to access the nursing and medication information during the licensing inspection. In addition, for the outpatient and partial hospitalization clients, some of the client record information was kept in another electronic record program that the licensing staff did not have access to.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
DDAP Surveyor will be provided with a full EMR auditor login. Senior Director of Compliance & Quality will reeducate facility staff on the full use of the auditor portal. The Quality Assurance Strategist will make available the portal to the surveyor(s) via a unique username and passcode. Quality Assurance Strategist will provide appropriate instructions to access the complete record. Login access will be tested by the Quality Assurance Strategist prior to the survey date. |
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.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for a the dated signature of the client on releases of information were submitted and approved by the Department for the April 15, 2022 and October 28, 2021 annual licensing inspections. Dated client signatures on the consents to release information were again found to be a deficiency in the April 24-26, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Deficiencies identified in the 04/26/2023 and previous surveys have been reviewed and plans of correction have been developed by site and corporate leadership. RCA Monroeville commits to following the plans submitted as approved by the department. Monitoring will be performed by Senior Director of Compliance & Quality at the corporate level and by the Quality Assurance Strategist at the site via the monthly QAPI Committee. |