INITIAL COMMENTS
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This report is a result of an onsite unusual incident investigation conducted June 1-4, 2021 at Recovery Center of America at Devon by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Recovery Center of America at Devon 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
The facility failed to ensure a safe environment. Based on a review of a police report dated 10/5/2019, there was evidence of drugs on the premises. The police were called to the facility in response to an unusual incident involving a patient that was found unresponsive and was transported to the hospital. The police report indicates drugs were found in a patient ' s bedroom when the police searched the patient ' s room.
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Plan of Correction
RCA does not agree with the conclusion that it failed to ensure a safe environment.
Since 10/5/19, numerous measures have been implemented at RCA Devon to further assure a clean and safe environment.
All patient rooms and common areas are cleaned daily, and a daily audit tool is utilized by the housekeeping team to document. Facility leadership comprised of Executive Director, QA Strategist, Housekeeping Manager, Facilities Manager and Director of Nursing conduct routine environment of care tours. Facility staff perform multiple regular checks of systems and locations related to safety.
The facility uses a TSA-approved body scanning device to screen all patients upon admissions for any contraband. All Admissions and Recovery Support staff are trained to perform thorough personal and belonging searches of every patient and their possessions upon admission. All patients are searched, and their belonging screened at admission.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to conduct patient rounds/monitoring every 30 minutes according to facility procedure. Based on a review of administrative documentation, detoxification patient rounds/monitoring are to be conducted every 30 minutes and documented on the facility's electronic system, the RCA Rounding Application. The facility failed to complete this process from 12 pm to 2 pm on 10/5/2019, specifically for patient #1, who was discovered by staff in his bedroom in an unresponsive state, at approximately 2:24 pm. It was reported that the facility's video surveillance shows that the patient was in his room between 12 and 2 pm and that the assigned staff did not enter the patient room during those hours.
Additionally, based on a review of administrative documentation, there is evidence that an employee falsified the rounds/monitoring records on the Client Observation Report. An employee documented that he completed the required 30 minute rounds on 10/5/2019 between 12 noon and 1 pm. However, based on a review of the employee Disciplinary Action Form, it was documented by the employee's supervisor that the video surveillance shows that the assigned patient was in his room from 12-2 pm and the employee did not enter the patient room during those hours. The employee was observed on video going into the patient's room around 2:24 pm.
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Plan of Correction
RCA does not agree with the conclusion that it failed to ensure a safe environment.
Since 10/5/19, multiple enhancements to the patient monitoring system have been implemented. RCA now utilizes a QR code-based system to monitor patients on at least an hourly basis (every 30 minutes for Detox LOC patients). The system combines electronic scanning devices (similar to an iPod) and QR codes on patient wristbands and located bedside. The system is supervised by the site CEO, Executive Director, Quality Assurance Strategist and Recovery Support Specialist Supervisor through daily reporting and live time monitoring 24/7.
Additionally, facility leadership comprised of the Quality Assurance Strategist, Recovery Support Specialist Supervisor, Executive Director and Director of Nursing perform weekly video and live reviews of patient monitoring records and procedure. These reviews cover all units and shifts.
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