INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Roxbury 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on one of four employee personnel records reviewed, the facility failed to provide documentation of the qualification of counselors for employee # 4, #7 and #10.
Employee # 4 was hired as a counselor on January 18, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 4's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree.
Employee # 7 was hired as a counselor on November 14, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 7's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree.
Employee # 10 was hired as a counselor on October 24, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 10's personal record and resume, there was no documentation of at least one year of clinical experience with a bachelor's degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee 4 has now achieved one year of additional experience in drug and alcohol and meets the requirements for Counselor status. The Clinical Supervisor conducted his annual evaluation and he signed an updated job description. Employees 7 and 10 had been receiving supervision since their hire; however, the notes were not officially on file and it was determined that they did not have the correct job description signed and filed with the HR department. Counselor Assistant job descriptions were completed and signed for Employees 7 and 10 and supervision/evaluation will continue until they achieve Counselor status. The HR department staff have been educated about the regulatory standards for assessing perspective employees for Counselor requirements and they will monitor compliance with a monthly audit of supervision notes filed. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #12 received the minimum 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #12 was hired as a intake lead on October 22, 2018 and was still in this position at the time of the inspection. Employee # 12 was due to have the communicable disease trainings no later than October 22, 2020. There was no documentation in the personnel file of the completion the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee 12 was scheduled for the next available TB/STD training, which will be held on 2/28/23. Immediately following the training, Employee 12 will forward her certificate to both her direct supervisor and the Director of HR to ensure follow up and completion. The Director of HR will monitor the required training dates through a new tracking process and ensure direct supervisors have ongoing communication regarding training due dates to maintain compliance. |
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
Based on the facility physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees, and visitors. Bedroom 28 had an outlet located above bed 3 that did not have a cover creating exposed wires.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time it was discovered that Room 28 was lacking an outlet cover, the Director of Plant Operations immediately notified maintenance staff and it was corrected and covered prior to any clients returning to the room. The Director of Plant Operations re-educated staff to ensure ongoing proper environment of care auditing/monitoring and client safety. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Cameras are in group rooms and allow therapy sessions to be recorded. In addition, group room doors have windows that are not covered that allow staff and visitor to see into the group while in session.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 19, 2022 licenisng inspection.
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Plan of Correction
The Director of Plant Operations ensured that window coverings are now in place for all group rooms. The CEO/Facility Director filed an exemption request letter to the department on 2/14/23 respectfully requesting parameters to permit cameras in common areas/large group meeting rooms to ensure safety. Currently, all counseling sessions are being held in counselor offices, where there are no cameras. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on the facility physical plant inspection, the facility failed to ensure that all food items were stored off the ground as there were drinks in the walk-in cooler stored directly on the floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the finding, the Dietary Manager was immediately notified and the issue was corrected in real-time and prior to the end of the inspection. The Director of Plant Operations re-educated the dietary manager and staff to ensure that that food items are never stored directly on the floor. Daily rounds will be conducted by the Dietary Manager, or her designee, to monitor for and ensure compliance. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on one of fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 8 was admitted on December 8, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 8, 2022 to an outside medical provider did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process
This repeat citation from the January 19, 2022 licensing inspection.
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Plan of Correction
The consent for Client 8 was corrected immediately. The Clinical Supervisor re-educated staff on ensuring that the specific information to be disclosed is always included on the consent. The Clinical Supervisor will complete weekly chart audits to ensure compliance. Continued education will occur, as necessary, throughout the monitoring process and audit results will be reported monthly through the Performance Improvement Committee. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on one of fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include if the client was offered a copy of the consent.
Client # 8 was admitted on December 8, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 8, 2022 to an emergency contact did not include if the client was offered a copy of the consent.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The consent for Client 8 was corrected immediately. The Clinical Supervisor re-educated staff on ensuring that the client's acceptance or refusal of a copy of the consent is always documented. The Clinical Supervisor will complete weekly chart audits to ensure compliance. Continued education will occur, as necessary, throughout the monitoring process and audit results will be reported monthly through the Performance Improvement Committee. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on five of fourteen client records reviewed, the facility failed to provide documentation of medication being provided as prescribed by a physician.
Client # 8 was admitted on December 8, 2022 and was still active at the time of the inspection. The client was prescribed medications to be taken daily. After a review of the facility medication administration records, there was no documentation of the medications given for the following dates:
December 14, 2022 and December 16, 2022.
Client # 9 was admitted on November 23, 2022 and was still active at the time of the inspection. The client was prescribed medications to be taken daily. After a review of the facility medication administration records, there was no documentation of the medications given for the following dates:
December 22, 2022 and December 31, 2022.
Client # 10 was admitted on November 22, 2022 and was still active at the time of the inspection. The client was prescribed medications to be taken daily. After a review of the facility medication administration records, there was no documentation of the medications given for the following dates:
December 13, 2022, December 22, 2022 and December 31, 2022.
Client # 11 was admitted on December 2, 2022 and was still active at the time of the inspection. The client was prescribed medications to be taken daily. After a review of the facility medication administration records, there was no documentation of the medications given for the following dates:
December 21, 2022
Client # 14 was admitted on May 19, 2022 and was discharged on August 30, 2022. The client was prescribed medications to be taken daily. After a review of the facility medication administration records, there was no documentation of the medications given for the following dates:
January 3, 2023
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 19, 2022 licensing inspection
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Plan of Correction
The Nurse Manager re-educated nursing staff on the Medication Administration policy, including the documentation requirements, to ensure that all medications administered are documented appropriately and according to policy. This education also included the proper documentation process staff should follow in the event that a client refuses a medication. The Nurse Manager, or her designee, will complete weekly audits of all medication administration records to ensure compliance. Continued education will occur, as necessary, throughout the monitoring process and audit results will be reported monthly through the Performance Improvement Committee. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on three of seven applicable residential client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in client records #10, 13 and 14.
Client # 10 was admitted on November 22, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on November 25, 2022. A treatment and rehabilitation plan update was due no later than December 25, 2022 however, there was no documentation of the treatment plan update in the client record.
Client # 13 was admitted on October 25,2022 and was discharged on January 3, 2023. A treatment and rehabilitation plan was developed on November 1, 2022. A treatment and rehabilitation plan update was due no later than December 1, 2022 however, there was no documentation of a treatment plan update in the client record.
Client # 14 was admitted on May 19, 2022 and was discharged on August 30, 2022. A treatment and rehabilitation plan was developed on May 24, 2022. A treatment and rehabilitation plan update was due no later than June 24, 2022 however, there was no documentation of a treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment plan updates that were found to be missing were corrected immediately. The Clinical Supervisor re-educated staff on the Treatment Planning Policy, including the timeframe and documentation requirements. The Clinical Supervisor, or her designee, will complete weekly chart audits to ensure that all treatment plan updates are completed per policy and in the required timeframe. Continued education will occur, as necessary, throughout the monitoring process and audit results will be reported monthly through the Performance Improvement Committee. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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 two of three applicable residential client records reviewed, the facility failed to provide a discharge summary.
Client # 12 was admitted on September 16, 2022 and was discharged on October 17, 2022. The client record did not contain documentation of a discharge summary being completed .
Client # 14 was admitted on May 19, 2022 and was discharged on August 30, 2022. The client record did not contain documentation of a discharge summary being completed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from January 19, 2022 licensing inspetion.
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Plan of Correction
The discharge summaries that were found to be missing were corrected immediately. The Clinical Supervisor re-educated staff on the components of the Discharge Summary, including the timeframe and documentation requirements. The Clinical Supervisor, or her designee, will complete weekly chart audits to ensure that all discharge summaries are completed per policy and in the required timeframe. Continued education will occur, as necessary, throughout the monitoring process and audit results will be reported monthly through the Performance Improvement Committee. |