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 23-24, 2025 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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705.10 (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.
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Observations
Based on a review of the fire drill records, the facility failed to maintain a written fire drill record that included all required components.
Fire drill records were reviewed from April 2024 to March 2025. Fire drills documented from November 2024 to March 2025 did not include the exit routes utilized during evacuation and the number of people evacuated. Additionally, March 2025 did not include the amount of time it took to evacuate.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RCA VP of Support Services updated the Fire Drill log on 5/8/25, to include exit route, number of persons evacuated, and time it took to evacuate. RCA at Monroeville Facility Director provided education to Facilities Manager on 5/8/25 regarding updates to the Fire Drill Log. RCA at Monroeville Facilities Manager will conduct post drill meeting to evaluate the efficiency of the staff and identify areas of improvement. Facilities Manager will report to Fire Drill results to the Safety Committee for ongoing monitoring, held monthly. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates according to agency policy and procedure in the partial hospitalization level of care in four of six applicable records reviewed.
The policy and procedure manual states that treatment plans will be updated every 14 days in the Partial Hospitalization level of care.
Client #8 was admitted August 22, 2024 and discharged October 14, 2024. A treatment plan was completed on August 26, 2024 and the update was due no later than September 9, 2024 but not completed until September 18, 2024. Another update was due by October 2, 2024 but not completed until October 9, 2024.
Client #9 was admitted October 24, 2024 and discharged November 26, 2024. A treatment plan was completed on October 31, 2024 and the update was due no later than November 14, 2024 but not completed until November 20, 2024.
Client #11 was admitted February 3, 2025 and discharged March 24, 2025. A treatment plan was completed on February 17, 2025 and the update was due no later than March 3, 2025 but not completed until March 13, 2025.
Client #12 was admitted February 13, 2025 and discharged April 7, 2025. A treatment plan was completed on March 3, 2025 and the update was due no later than March 17, 2025 but not completed until March 18, 2025. The next update was due by April 1, 2025, but was not completed prior to discharge.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
RCA at Monroeville Clinical Director conducted a training session with Outpatient Therapist on 4/28/25, that included RCA Treatment Plan Policy that specifies a patient in in an PHP LOC will have treatment plan update every 14-days. The Clinical Director or designee will conduct a weekly review of PHP charts for a 3-month period with the goal of achieving 90% compliance for case consultation notes every 14 days. Clinical Director will report audit findings monthly to the Medical Records Committee, held monthly. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to complete case consultations according to agency policy and procedure manual timeframes in four of six applicable records reviewed.
Agency P&P states case consultation will be completed every 7 days for clients in Partial Hospitalization level of care.
Client #9 was admitted October 24, 2024 and discharged November 26, 2024. Client #9 case consultation was due by October 31 but not completed until November 19, 2024.
Client #11 was admitted on February 3, 2025 and discharged March 24, 2025. Client #11 case consultation was due by February 26 but was not completed until March 24, 2025.
Client #12 was admitted on February 13, 2025 and discharged April 7, 2025. Client #12 case consultation was due by February 27 but was not completed until March 13, 2025.
Client #14 was admitted on March 31, 2025 and still a current client. Client #14 case consultation was due by April 6 but was not completed until April 22, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RCA at Monroeville Clinical Director conducted a training session with Outpatient Therapists on 4/28/25, that included the RCA Treatment Plan Policy that specifies Treatment Planning by a Multidisciplinary Team (MDT) recommendations reviewed every 7-days for patients at in a PHP LOC. The Clinical Director or designee will conduct a weekly review of PHP charts for a 3-month period with the goal of achieving 90% compliance for case consultation notes every 7 days. The Clinical Director will report the audit finding monthly to the Medical Records Committee, held monthly. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to provide, in writing, documentation that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in one of two applicable records.
Patient #25 was transferred from another narcotic treatment program and admitted on December 6, 2024 and discharged on December 23, 2024. The patient ' s record did not have documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
RCA at Monroeville Director of Nursing (DON) conducted a training session on 5/5/25 with nursing staff regarding documenting ongoing communication with referring Methadone Clinic to include notification of receiving the dosing letter, initial dose and date given to patient. The Director of Nursing (DON) or designee will conduct a 3-month chart review of all Methadone patients admitted to RCA at Monroeville. The chart review will consist of nursing documentation that reflects communication from RCA to the referring Methadone Clinic 1. Methadone Clinical dosing letter received, 2. Patient's initial Methadone dose administered, and 3. Date of initial Methadone dose administered. DON will provide monthly outcomes of the 3-month audit during the Medical Records Committee, held monthly. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to complete case consultations according to agency policy and procedure manual timeframes for outpatient level of care in five out of six records reviewed.
Agency P&P states case consultation will be completed every 14 days for clients in Intensive Outpatient level of care and every 28 days in outpatient level of care.
Client #1 was admitted to IOP on October 14, 2024 and stepped down to outpatient on January 10, 2025 and discharged April 1, 2025. A case consultation was completed on October 21, 2024 and another was due by November 4, 2024 but not completed until December 3, 2024. Another case consultation was due by December 17, 2024 but not completed until January 9, 2025. A case consultation was due by February 6, 2025 but no additional case consultations were completed prior to discharge.
Client #3 was admitted to IOP on November 26, 2024 and discharged April 1, 2025. Client #3 case consultation was due by December 10, 2024 but not completed until December 23, 2024. A case consultation was completed on January 8, 2025 and another was due by January 22, 2025 but not completed until February 10, 2025. A case consultation was due by February 24, 2025 but no additional case consultations were completed prior to discharge.
Client #4 was admitted to outpatient on November 3, 2024 and discharged March 30, 2025. A case consultation was completed January 13, 2025 and another was due by February 10, 2025 but no additional case consultations were completed prior to discharge.
Client #5 was admitted to IOP on November 21, 2024 and discharged February 12, 2025. Client #5 case consultation was due by January 29, 2025, but was not completed prior to discharge.
Client #6 was admitted to IOP on February 19, 2025 and discharged March 12, 2025. Client #6 case consultation was due by March 10, 2025, but was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RCA at Monroeville Clinical Director conducted a training session with Outpatient Therapist on 4/28/25, that included RCA Treatment Plan Policy regarding treatment plan updates every 14 days for IOP patients and every 28 days for GOP patients. The Clinical Director or designee will conduct a weekly review of IOP and GOP charts for a 3-month period with the goal of achieving 90% compliance for treatment plan updates notes every 14 days for IOP and every 28 days for GOP LOC. Clinical Director will report audit findings monthly to the Medical Records Committee, held monthly. |