INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 14-15, 2022 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
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document a written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor, new employees within 30 days from date of hire.Employee #12 was hired on January 3, 2022 and the training plan was not completed until March 4, 2022.Employee #16 was hired on January 3, 2022 and the training plan was not completed until February 21, 2022.These finding were reviewed with the facility staff during the licensing process.
|
Plan of Correction
New employee orientation is conducted
the first week of hire. Within this period
the facility will provide a written
individualized training plan for each new
employee, appropriate to that employee's
skill level, and shall be reviewed and
signed by the employee and supervisor
within 30-days from date of hire.
This will be monitored and reviewed via
QAPI Committee, held monthly. |
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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in five out of twenty-eight client records reviewed.Client #15 was admitted on February 21, 2022 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated February 21, 2022 for an insurance company, however the client did not sign the informed and voluntary consent. The facility contacted the insurance company on February 21, 2022. Client #16 was admitted on March 18, 2022 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated March 18, 2022 for an insurance company, however the client did not sign the informed and voluntary consent. The facility contacted the insurance company on March 18, 2022. Client #18 was admitted on March 14, 2022 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated March 14, 2022 for an insurance company, however the client did not sign the informed and voluntary consent. The facility contacted the insurance company on March 14, 2022.Client #22 was admitted on March 4, 2022 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated March 4, 2022 for an insurance company, however the client did not sign the informed and voluntary consent. The facility contacted the insurance company on March 4, 2022.Client #23 was admitted on March 18, 2022 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated March 18, 2022 for an insurance company, however the client did not sign the informed and voluntary consent. The facility contacted the insurance company on March 18, 2022.These finding were reviewed with the facility staff during the licensing process.
|
Plan of Correction
RCA-Monroeville Outpatient utilizes
DocuSign program to obtain written
consent from patients. Education regarding
this process was conducted on 4/26, 4/27,
and 4/28/22 with Therapist. In addition, the Outpatient Clinical Director reviewed the process again on 5/25/22. All current
patient's medical records were reviewed
and consents obtained as of 6/3/22.
This will be monitored and reviewed via
Outpatient Medical Records Committee
held monthly. |
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 the review of client records, the facility failed to document an informed and voluntary consent to release information form with a dated signature of the client one out of twenty-eight client records reviewed.Client # 17 was admitted on February 28, 2022 and was still active at the time of the inspection. A consent to release information was signed by a witness on February 28, 2022 for a family member, however the client did not sign the informed and voluntary consent.This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the October 28, 2021 licensing inspection.
|
Plan of Correction
RCA-Monroeville Outpatient utilitizes
DocuSign program to obtain written consent
from patients. Education regarding this
process was conducted on 4/26, 4/27, and
4/28/22 with Therapist. In addition, the
Outpatient Clinical Director reviewed the
process again on 5/25/22. All current
patient's medical record reviewed and
consents obtained as of 6/3/22.
This will be monitored and reviewed via
Outpatient Medical Records Committee held
monthly. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of the client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in one out of one client record reviewed. Client #14 was admitted to the facility on December 27, 2022, and administratively discharged on January 21, 2022. These findings were reviewed with the facility staff during the inspection process.
|
Plan of Correction
Inpatient Clinical Director conducted a
training and education session with clinical staff regarding client(s) receiving notification of termination, in writing, of a decision to involuntarily terminate the client(s) from treatment on 5/4/22.
This will be monitored via Medical Records
Committee, held monthly. |
709.83(a)(6) 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:
(6) Aftercare plans, if applicable.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare information in one out of one applicable discharged records reviewed.Client #21 was admitted on March 9, 2022 and was discharged on April 5, 2022. The finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Outpatient Clinical Director provided
training and reviewed the Coordination of
Care Form with all staff on 5/25/22, which
includes aftercare information upon
discharge. In addition, the Outpatient
Clinical Director implement supervision
once per month with OP Therapists.
This will be monitored and reviewed via
Outpatient Medical Records Committee
held monthly. |
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of three applicable discharged records reviewed.Client #21 was admitted on March 9, 2022 and was discharged on April 5, 2022. The finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Outpatient Clinical Director provided
education and trainings regarding the use
of the Outpatient Discharge Summary
Report and completion of discharge
summaries within 30-days of the discharge
date to all outpatient therapist completed
on 6/1/22.
This will be monitored via Outpatient
Medical Records Committee held monthly. |
709.83(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of three applicable discharged records reviewed.Client #21 was admitted on March 9, 2022 and was discharged on April 5, 2022. The finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Outpatient Clinical Director provided
training and education to therapist on
6/3/22 regarding follow up letters being
sent to discharged patients via Therapist.
This will be monitored via Outpatient
Medical Records Committee held monthly. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
|
Observations
Based on a review of the patient records, the facility failed to ensure that prior to administration of an agent, a narcotic treatment physician documented in the patient's record the basis for the determination of current dependency and evidence of a one year history of addiction. Patient #3 was admitted to the facility on April 9, 2022 and was still active at the time of the inspection. Patient #3 was administered his first dose of an agent on April 14, 2022, at 12 AM.The finding was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
RCA-Monroeville Medical Director will
conduct a Face-to-Face assessment with
the patient and document in the Medical
Record the determination of whether the
individual is currently physiologically
dependent upon a narcotic drug and has
been physiologically dependent for at least
1 year prior to admission for maintenance
treatment.
This will be monitored via Inpatient
Medical Records Committee held monthly. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on a review of the policy and procedures manual and patient records, the facility failed to inform all patients and include in their policy and procedures manual, that methadone is transmitted to the unborn child and will cause physical dependence in four out of four patient records reviewed. These findings were reviewed with the facility staff during the inspection process.
|
Plan of Correction
Policy will be reviewed and revised by
Operations, Medical, Quality Assurance,
and the Policy and Procedures committee
and will include to all patients that
methadone is transmitted to the unborn
child and will cause physical dependence. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
Based on a review of the patient records, the facility failed to document in the patient record that a narcotic treatment physician who conducted the patient examination consulted with the narcotic treatment physician who determined the initial dose and schedule prior to the dose being administered in two out of the four patient records reviewed. Patient # 1 was admitted to the facility on April 12, 2022 and was still an active patient at the time of the inspection. Patient # 3 was admitted to the facility on April 9, 2022 and was still an active patient at the time of the inspection. These findings were reviewed with the facility staff during the inspection process.
|
Plan of Correction
RCA-Monroeville Medical Director shall
determine the proper dosage level for a
patient. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who
performed the examination before
determining the patient's initial dose and
schedule.
This will be monitored via Inpatient
Medical Records Committee held monthly |
715.15(f) LICENSURE Medication dosage
(f) The narcotic treatment program shall develop written policies and procedures relating to narcotic treatment medication dosage which includes the requirements of subsections (a)--(e).
|
Observations
Based on a review of the policy and procedures manual, the facility failed to include policy and procedures for when the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient evaluation in buprenorphine patients.These findings were reviewed with the facility staff during the inspection process.
|
Plan of Correction
Policy will be reviewed and revised by
Operations, Medical, Quality Assurance,
and the Policy and Procedures committee
and will include procedures for when the
narcotic treatment physician determining
the initial dose is not the narcotic treatment
physician who conducted the patient
evaluation in buprenorphine patients. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
|
Observations
Based on a review of the policy and procedures manual, the facility failed to include policy and procedures for regulations 715.17(c)(1)(i)(iii)(iv) and (vi).These findings were reviewed with the facility staff during the inspection process.
|
Plan of Correction
Policy will be reviewed and revised by
Operations, Medical, Quality Assurance,
and the Policy and Procedures committee and will include the following:
1. A narcotic treatment physician shall
determine the patient's initial and
subsequent dose and schedule. The
physician shall communicate the
initial and subsequent dose and
schedule to the person responsible for
the administration of medication.
Each medication order and dosage
change shall be written and signed by
the narcotic treatment physician.
2. Only authorized staff and patients
who are receiving medication shall be
permitted in the dispensing area.
3. There shall be only one patient
permitted at a dispensing station at
any given time.
4. Administering and dispensing shall
be conducted in a manner that
protects the patient from disruption
or annoyance from other individuals. |
715.20 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.
|
Observations
Based on a review of the policy and procedures manual, the facility failed to include the requirement to transfer patients within seven days of the transfer request. These findings were reviewed with the facility staff during the inspection process.
|
Plan of Correction
Policy will be reviewed and revised by
Operations, Medical, Quality Assurance,
and the Policy and Procedures committee
and will include the requirement to
transfer patients within seven days of the
transfer request. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
|
Observations
Based on a review of the policy and procedures manual, the facility failed to include policy and procedures to respond to complaints of patient abuse to include emotional abuse and drug related hospitalization of a patient. These findings were reviewed with the facility staff during the inspection process.
|
Plan of Correction
Policy will be reviewed and revised by the
Safety Committee, Privacy and Risk
Manager, Operations, Patient Safety & Risk
Program Manager, Quality Assurance, and
the Policy and Procedures committee and
will include procedures to respond to
complaints of patient abuse to include
emotional abuse and drug related
hospitalization of a patient. |
709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not limited to, written documentation of proposed type of supportive services in seven out of seven client records reviewed. These findings were reviewed with facility staff at during the licensing process.
|
Plan of Correction
Inpatient Clinical Director training and
education on 4/27/22 with Clinical Team
and discussed documentation of patient's
supportive services within the Treatment
Plan. Primary Therapist will include
Supportive Services within the Treatment
Plan.
This will be monitored via Inpatient
Medical Records Committee held monthly |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare plan in one out of one applicable discharged records reviewed.Client #28 was admitted on February 28, 2022 and was discharged on April 5, 2022. The finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Outpatient Clinical Director conducted
training and education on 5/26/22 with the
Outpatient Clinical Team discussing
documentation of Aftercare Planning.
This will be monitored via Outpatient
Medical Records Committee held monthly. |