INITIAL COMMENTS
|
This report is a result of an on-site provisional license follow-up inspection conducted October 11-12, 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
|
709.28 (c) 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.
|
Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent of the client on the release of information form prior to disclosure in two of twelve client records.
Client #3 was admitted to outpatient treatment on July 3, 2023 and was still active at the time of the inspection. A release of information signed for a funding source was not signed by the client, but "verbal " was written in the client signature line.
Client # 11 was admitted to outpatient treatment on July 25, 2023 and was still active at the time of the inspection. A release of information signed for a funding source was not signed by the client, but "verbal " was written in the client signature line.
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 November 8, 2023, regarding the completion and documentation of client signature and date for all release of information. This will be monitored via Outpatient Medical Record 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 in three of twelve client records.
Client #8 was admitted to detoxification treatment on September 12, 2023. Release of information forms for a primary care physician, a funding source and an emergency contact did not include the purpose of the disclosure.
Client # 11 was admitted to outpatient treatment on July 25, 2023 and was still active at the time of the inspection. Release of information form for an individual did not include the purpose of the disclosure.
Client #12 was admitted to outpatient treatment on July 3, 2023 and was discharged on August 31, 2023. A release of information form for a funding source did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the April 26, 2023 annual licensing inspection.
|
Plan of Correction
RCA at Monroeville commits to following the plan submitted as approved by the department. All Release of Information (ROI) documents currently include the purpose of disclosure, when printed. Corporate Compliance and IT Clinical Applications have reviewed the applications within the Electronic Health Record (EHR) system and will modify the view report function for all ROI consents. This modification will be completed by January 15, 2024. Monitoring of the ROI consents will be performed by Quality Assurance Strategist at the site via the monthly Medical Records Committee. |
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 six of twelve client records.
Client # 2 was admitted to partial hospitalization treatment on August 29, 2023 and was still active at the time of the inspection. Releases of information signed for another individual, a primary care physician, and a funding source were signed by the client, but not dated.
Client #8 was admitted to detoxification treatment on September 12, 2023. Release of information forms for individuals and law enforcement were signed by the client, but not dated.
Client # 9 was admitted to detoxification treatment on September 30, 2023 and was still active at the time of the inspection. Releases of information signed for family contact, and treatment providers were signed by the client, but not dated.
Client #10 was admitted to detoxification treatment on September 14, 2023 and was discharged on October 2, 2023. Releases of information signed for a hospital and a funding source were signed by the client, but not dated.
Client # 11 was admitted to outpatient treatment on July 25, 2023 and was still active at the time of the inspection. A release of information form for a government agency was signed by the client, but not dated.
Client #12 was admitted to outpatient treatment on July 3, 2023 and was discharged on August 31, 2023. Releases of information signed for another individual, and a funding source 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 26, 2023, April 15, 2022 and October 28, 2021 annual licensing inspections.
|
Plan of Correction
RCA-Monroeville Outpatient Clinical Director conducted a training and education with Outpatient Clinical staff on November 8, 2023, regarding the completion and documentation of client signature and date for all release of information. This will be monitored via Outpatient Medical Record Committee, 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 client records, the facility failed to maintain a complete client record which includes information relative to the client's involvement with the project in two of four client records.
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 supposed to be uploaded to the main system, so the client record is complete. This information was not uploaded for the outpatient clients reviewed; therefore, they are not complete client records.
Two of the four client records, #3 and #12 are missing the " Outpatient Admission Consent record " form which includes intake information; the consent to treatment and the handbook which includes client rights.
Client #3 was admitted to outpatient treatment on July 3, 2023 and was still active at the time of the inspection.
Client #12 was admitted to outpatient treatment on July 3, 2023 and was discharged on August 31, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the April 26, 2023 annual licensing inspection.
|
Plan of Correction
RCA-Monroeville Outpatient Clinical Director conducted a training and education with Outpatient Clinical staff on November 8, 2023 regarding maintaining a complete medical record. After the initial assessment, the individual therapist will be responsible for making sure all documentation is in the chart. This will be monitored via Outpatient Medical Record Committee, held monthly. |
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 the dated signature of the client on releases of information were submitted and approved by the Department for the April 26, 2023, 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 October 11 - 12, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the April 26, 2023 annual licensing inspection.
|
Plan of Correction
Deficiencies identified in the 10/11/2023 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. |