INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted July 14-15, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Recovery Centers 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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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based on client and staff interviews along with a review of Recovery Support Staff (RSS) schedules and the client census during the week of May 18, 2025, the facility failed to insure sufficient support staff for the safe operation of the project.
The facility's Observation of Patient policy indicates that staff must conduct visual checks to ensure the presence and safety of all current patients. Standard Observation Status rounds occur every 30 minutes at the Detoxification level of care and every 60 minutes at the Residential level of care. Close Observation Status will occur when ordered in the Detoxification or Residential levels of care every 15 minutes or every 30 minutes.
In addition, the facility's Patient Rounds and Monitoring Protocol indicates that if a patient is sleeping, staff shall: observe the rise and fall of the patient ' s chest a minimum of 3 times, verify patient ' s identity, locate and scan the bedside QR code, and report any physiological/physical distress, or discomfort observed, or reported by a patient to nursing immediately for follow-up.
On May 18 the total client census was 78 clients and there were 3 RSS between 12 pm - 12:30 pm, 1:30 pm- 2:00 pm, 2:30 pm - 3:00 pm, 7:30 pm-8:00 pm, 8:30 pm-9:00pm, and 9:30 pm-10:00pm. There were 3 RSS from 11:30pm - 11:46 pm and 2 RSS from 11:46 pm to 12:00 midnight.
On May 19 the total client census was 76 clients and there were 2 RSS from 12:00 am - 2:23 am. and from 2:53 am to 4:49 am. From 2:23 am to 2:53 am there was 1 RSS. From 4:49 am to 7 am there were 3 RSS. There were 3 or less RSS from 1:00 pm - 2:30pm, 3:30 pm - 4:00 pm, 7:30 pm - 9:00 pm, and 11:30 pm until 12:00 midnight.
On May 20 the total client census was 77 clients and there were 1-2 RSS from 12:00 am - 7:00 am. 3 RSS from 7:30 am -9:00 am, 1:30 pm-2:00 pm, and 11:30 pm-12:00 am.
On May 21 the total client census was 77 clients and there were 3 or less RSS from 12:00 am - 6:30 am, 10:30 pm-11:00 pm, and 11:30 pm - 12:00 am.
On May 22 the total client census was 77 clients and there were 1-3 RSS from 12:00 am - 7:00 am. 2-3 RSS from 8:30 pm-9:30 pm, 10:00 pm -11:00 pm, and 11:30 pm - 12:00 midnight.
On May 23 the total client census was 78 clients and there were 1-2 RSS from 12:00 am - 7:00 am. 3 RSS staff from 9:00 pm - 9:30 pm, and 11:30 pm - 12:00 am.
On May 24 the total client census was 76 clients and there were 2-3 RSS from 12:00 am - 7:00 am. 3 RSS from 10:00 pm - 12:00 midnight.
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Plan of Correction
The project will ensure sufficient support staffing by ensuring staff is scheduled in adherence to the internal plan and to ensure rounding compliance is met as outlined by enterprise rounding policy and protocol. Effective 8/4/25, DON will educate the nursing team on covering breaks on their assigned unit to ensure rounding compliance. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on staff interviews along with a review of primary care staff timesheets, and the client census during the week of May 18, 2025, the facility failed to comply with the client to primary care staff ratio for detoxification patients.
On May 19 there were 26 detoxification clients. There were 2-3 primary care staff working between 3:46 am and 4:46 am. There should have been 4 primary care staff working during that time.
On May 20 there were 29 detoxification clients. There were 3 primary care staff working between 1:30 am and 2:30 am, 3:28-3:59 am, and 6:12-6:53am. There should have been 5 primary care staff working.
On May 21 there were 27 detoxification clients. There were 2-3 primary care staff working between 1:04 am and 1:34 am, and again from 4:00 am until 5:08 am. There should have been 4 primary care staff.
On May 23 there were 28 detoxification clients. There were 2-3 primary care staff working between 4:37 am and 5:03 am. There should have been 4 primary care staff.
On May 24 There were 24 detoxification clients. There were 3 primary care staff working from 3:12 am until 3:42 am. There should have been 4 primary care staff.
In addition, during client and staff interviews it was reported that primary care staff leave the floors where detoxification patients are located to perform other duties. Also, during a physical plant inspection on July 14, 2025, it was observed that new admissions are processed on the first floor which does not house detoxification patients.
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Plan of Correction
Effective 7/16/25, the project will ensure that primary care staff coverage adheres to state regulation and ratio including any regulatory flexibilities submitted by the project and with the project's internal plan. Effective 7/30/25, DON re-educated all nursing staff on staggering break times during shift. Effective 8/4/25, Lead nurse on shift will be assigning break times for nursing staff and will be responsible for ensuring one nurse is on break at a time as staffing allows. |
709.30 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.
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Observations
Based on client and staff interviews along with a review of client grievances, the facility's Search Policy and the Patient Handbook, the facility failed to follow its procedures on client rights.
The Patient Rights indicates all patients of Recovery Centers of America have the following rights: Treatment with dignity and respect.
The Search Policy in the Patient Handbook indicates that RCA will conduct an inventory of all client belongings brought into the facility upon admission, as well as any additional items that are brought into the facility.
All of the clients and staff interviewed reported that all of the client belongings are not being searched due to limited staff availability. Also, it was reported that some clients had to wait several days to obtain clean clothing, underwear, and hygiene products from their belongings.
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Plan of Correction
The project identified inadequate training during the initiation of belonging's process. The project will ensure compliance with the internal plan and conduct a re-training on this process 8/6/25 by the Site Trainer. |