INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring inspection conducted on April 16, 2025 through April 18, 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 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection on April 16, 2025, the facility failed to store eating utensils in an enclosed area. The utensils were in an unenclosed area in the dining hall at 10:42 a.m., between the breakfast and lunch meals.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 4/21/25, Dining Manager implemented a revised checklist inclusive of dining staff accounting for the removal of silverware from station and bringing silverware back to enclosed area in between meal service. Dining Manager provided education to dining staff on 4/21/25. Dining Manager will ensure proper storage of utensils utilizing the daily checklist and through monthly environment of care walkthroughs. Dining Manager will report on compliance during quarterly Infection Control Committee meetings. |
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 fire drill logs from May 2024 through February 2025, the facility failed to ensure that fire drill logs included the exit route used and the number of persons in the facility at the time of the drill as both were missing on the log for February 2025. The January 2025 log was missing the exit route used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 4/17/25, Director of Facilities implemented a new fire drill log form inclusive of the number of people involved in the evacuation and the exit route. Director of Facilities will audit fire drill logs monthly upon the completion of monthly drills. This data will be reported during monthly Safety Committee meeting. |
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.
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Observations
Based on a review of twenty-eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 11 was transferred to the inpatient non-hospital level of care on March 7, 2025 and was discharged on March 25, 2025. There was evidence of disclosures to a family member during a family counseling session on March 21, 2025; however, the record did not contain a client signed consent to release information form allowing the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/21/25, clinical and case management staff were re-educated during treatment team meeting on verifying consents and appropriate PHI disclosures to intended individuals. QI tracks privacy exposure incidents daily through incident reporting and reports monthly during Safety Committee meeting. Clinical Supervisor will be responsible for ensuring compliance with privacy regulations and will review with clinical staff during clinical supervisions. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of fourteen applicable client records, the facility failed to ensure that verbal orders were authenticated in writing by a physician or other medical professional within the regulatory timeframe in six records reviewed.
Client # 2 was admitted to the detoxification level of care on October 4, 2024 and was transferred to a lower level of care on October 11, 2024. Verbal orders were given on October 5, 2024z, October 6, 2024, and October 7, 2024, that were not authenticated by an authorized provider as of the date of the inspection.
Client # 3 was admitted to the detoxification level of care on February 23, 2025 and was transferred to a lower level of care on March 7, 2025. A verbal order was given on March 1, 2025, that was not authenticated in writing by an authorized prescriber until March 3, 2025.
Client # 5 was admitted to the detoxification level of care on March 27, 2025 and was transferred to a lower level of care on April 4, 2025. Verbal orders were given on March 27, 2025, that were not authenticated by an authorized provider until April 2, 2025.
Client # 6 was admitted to the detoxification level of care on March 28, 2025 and was transferred to a lower level of care on April 4, 2025 of the inspection. Verbal orders were given on March 28, 2025, that were not authenticated by an authorized provider until April 2, 2025.
Client # 7 was admitted to the detoxification level of care on April 11, 2025 and was active at the time of the inspection. Verbal orders were given on April 11, 2025, that were not authenticated by an authorized provider until April 16, 2025. One verbal order given on April 11, 2025, was not authenticated as of the date of the inspection.
Client # 9 was admitted to the inpatient non-hospital level of care on December 13, 2024 and was discharged on December 19, 2024. A verbal order was given on December 13, 2024, that was not authenticated by an authorized provider until January 21, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 5/19/25, Medical Director will be distributing the verbal order report daily to all providers. Medical Director will audit verbal order report daily to ensure completion and obtain data on outstanding validations. Medical Director and QI will meet weekly until we reach compliance of 90% for consecutive 90 days. |
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 review of client records and the policy and procedure manual, the facility failed to document treatment plan updates according to the project's written procedures in three of five applicable client records reviewed. The policy and procedure manual stated that treatment plans will be updated every 14 days in the partial hospitalization level of care.
Client # 15 was admitted to the partial hospitalization level of care on July 19, 2024 and was transferred to a lower level of care on August 30, 2024. The comprehensive treatment plan was completed on August 2, 2024, and the treatment plan update was due to be completed by August 16, 2024; however, the plan was not updated prior to the level of care change.
Client # 16 was admitted to the partial hospitalization level of care on November 14, 2024 and was transferred to a higher level of care on December 12, 2024. The comprehensive treatment plan was completed on November 18, 2024, and the treatment plan update was due no later than December 2, 2024; however, the plan was not updated prior to the level of care change.
Client # 21 was transferred to the partial hospitalization level of care on March 25, 2025 and was active at the time of the inspection. The comprehensive treatment plan was completed on March 27, 2025, and the treatment plan update was due no later than April 10, 2025; however, the plan was not updated until April 16, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 4/24/25, Outpatient Director held a treatment plan training for all clinical staff pertaining to reviewing and updating treatment plans within required timeframe. Treatment plan updates for Partial level of care will be audited monthly at 5 charts with goal of 90% compliance. Data compliance will be reported by QI during monthly Medical Record Committee meeting. |
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 and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in five of seven records reviewed. The facility policy manual indicates that case consultation notes will be completed weekly for clients in the partial hospitalization level of care.
Client # 15 was admitted to the partial hospitalization level of care on July 19, 2024 and was transferred to a lower level of care on August 30, 2024. The record did not contain documentation of weekly case consultation notes.
Client # 18 was admitted to the partial hospitalization level of care on September 3, 2024 and was discharged on October 28, 2024. The record did not contain documentation of weekly case consultation notes.
Client # 19 was admitted to the partial hospitalization level of care on May 31, 2024 and was transferred to a different level of care on July 2, 2024. The record did not contain documentation of weekly case consultation notes.
Client # 20 was transferred to the partial hospitalization level of care on March 26, 2025 and was active at the time of the inspection. The record did not contain documentation of weekly case consultation notes.
Client # 21 was transferred to the partial hospitalization level of care on March 25, 2025 and was active at the time of the inspection. The record did not contain documentation of weekly case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 5/15/25, Outpatient Director re-educated outpatient staff on documentation of case consultation for all levels of outpatient care. Outpatient Director will audit 10 charts per month with compliance goal of 90% to ensure case consultation is documented via Outpatient Case Management note. Case Consultations will be documented in the chart following weekly treatment team meetings. Case Consultation compliance will be reported by Outpatient Director during monthly Medical Records Committee meeting. |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary, in one of two applicable records reviewed.
Client # 18 was admitted to the partial hospitalization level of care on September 3, 2024 and was discharged on October 28, 2024. The record did not contain a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 5/15/25, Outpatient Director re-educated outpatient staff on discharge summary completion. Discharge summaries are audited monthly as part of routine medical record audits. 5 charts audited monthly to obtain compliance data. This data will be reported by Outpatient Director or QI during monthly Medical Records Committee meeting. |
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.
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Observations
Based on a review of patient records, the facility failed to ensure that verification of the individual's identity was obtained during the intake process in one of four applicable records reviewed.
Patient # 3 was admitted to the detoxification level of care on February 23, 2025 and was transferred to a lower level of care on March 7, 2025. The record did not contain documentation that the individual's identity was verified during intake.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 5/14/25, Director of Admissions has educated the admission's staff on the Patient Identification Attestation form. Effective 5/14/25, admission's staff will be responsible for uploading a patient's ID card if applicable upon admission. For patients without photo ID or ID verification, admission's staff will be responsible for outreach attempts to obtain a valid photo ID and document accordingly in the patient record. If attempts are unsuccessful, admissions staff will be completing the patient identification attestation form as a signed attestation by the patient reflecting accuracy in identification information provided. Additionally, for patients without a valid photo ID, utilization review will be responsible for obtaining a demographic sheet from the insurer to verify identity. 10 charts will be audited monthly as part of medical records to audit for verification of identification. Plan will discontinue after 90% compliance for consecutive 90 days. QI will report on identity verification during monthly Medical Records Committee meeting. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four of six applicable records reviewed.
Client # 23 was transferred to the outpatient level of care on August 9, 2024 and was transferred to a higher level of care on March 12, 2025. The comprehensive treatment plan was completed on August 9, 2024, and the treatment plan update was due to be completed by October 8, 2024; however, the update was not completed until October 21, 2024. The next treatment plan update was due to be completed by December 20, 2024; however, no additional treatment plan updates were completed prior to level of care change.
Client # 24 was admitted to the outpatient level of care on October 18, 2024 and was discharged on March 3, 2025. The comprehensive treatment plan was completed on October 23, 2024, and the treatment plan update was due to be completed by December 22, 2024; however, the treatment plan update was not completed until January 20, 2025.
Client # 25 was transferred to the outpatient level of care on September 3, 2024 and was discharged on November 7, 2024. The most recent completed treatment plan was while the client was in a higher level of care on August 30, 2024, and no treatment plan updates were completed during the outpatient level of care.
Client # 26 was admitted to the outpatient level of care on November 27, 2024 and was active at the time of the inspection. A treatment plan update was completed on January 30, 2025, and the next update was due no later than March 31, 2025; however, no additional treatment plan updates were completed prior to the date of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 4/24/25, Outpatient Director held a treatment plan training for all clinical staff pertaining to reviewing and updating treatment plans within required timeframe. Treatment plan updates for outpatient levels of care will be audited monthly as part of routine medical records. Treatment plan update compliance based on 5 monthly chart audits with goal of 90% compliance. This data will be reported by QI during monthly Medical Records Committee meeting. |
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 and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in seven of seven records reviewed. The facility policy manual indicates that case consultation notes will be completed biweekly for clients in the outpatient level of care.
Client # 22 was transferred to the outpatient level of care on August 30, 2024 and was discharged on October 15, 2024. The record did not contain documentation of biweekly case consultation notes.
Client # 23 was transferred to the outpatient level of care on August 9, 2024 and was transferred to a higher level of care on March 12, 2025. The record did not contain documentation of biweekly case consultation notes.
Client # 24 was admitted to the outpatient level of care on October 18, 2024 and was discharged on March 3, 2025. The record did not contain documentation of biweekly case consultation notes.
Client # 25 was transferred to the outpatient level of care on September 3, 2024 and was discharged on November 7, 2024. The record did not contain documentation of biweekly case consultation notes.
Client # 26 was admitted to the outpatient level of care on November 27, 2024 and was active at the time of the inspection. The record did not contain documentation of biweekly case consultation notes.
Client # 27 was admitted to the outpatient level of care on January 7, 2025 and was active at the time of the inspection. The record did not contain documentation of biweekly case consultation notes.
Client # 28 was admitted to the outpatient level of care on February 19, 2025 and was active at the time of the inspection. The record did not contain documentation of biweekly case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 5/15/25, Outpatient Director re-educated the outpatient staff on documentation of case consultation for all levels of outpatient care. Outpatient Director will audit 10 charts per month with compliance goal of 90% to ensure case consultation is documented via Outpatient Case management note. Case Consultations will be documented in the chart following weekly treatment team meetings. Case Consultation compliance will be reported by Outpatient Director during monthly Medical Records Committee meeting. |