INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted August 25, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Roxbury 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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709.53(a)(6) LICENSURE Ind. Tx. Plan
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:
(6) Individualized treatment and rehabilitation plan.
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Observations
The facility failed to ensure that client records include individualized treatment and rehabilitation plans.
During a complaint investigation on August 25, 2021, three out of four client records included treatment plans that were exactly the same. The treatment plans were not individualized for each client. This was discussed with the facility at the time of the complaint investigation.
Client #1 was admitted on 6/22/21 and is currently in treatment.
Client #2 was admitted on 3/17/21 and discharged on 3/24/21.
Client #3 was admitted 7/20/21 and is currently in treatment.
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Plan of Correction
Clinical staff have been provided re-education by the Clinical Supervisor on ensuring that individualized treatment plans are developed for all patients. The Director of Clinical Services or Clinical Supervisor will provide oversight via random weekly chart audits. Any issues with compliance of regulation 709.53 will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The facility failed to ensure that the work done by clients at the project is an integral part of the clients' treatment and rehabilitation plan.
During a complaint investigation on August 25, 2021, all of the interviewed clients reported doing regular work (cleaning the facility twice a week) beyond cleaning their personal living space/bedroom. The clients all reported that this was not part of their treatment plan goals. In addition, none of the client records reviewed included work at the facility as a goal on the treatment plans. This was discussed with the facility at the time of the complaint investigation.
Client #1 was admitted on 6/22/21 and is currently in treatment.
Client #2 was admitted on 3/17/21 and discharged on 3/24/21.
Client #3 was admitted 7/20/21 and is currently in treatment.
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Plan of Correction
Clinical staff have been provided re-education by the Clinical Supervisor on ensuring that treatment plan goals specifically capture any work, cleaning, and other life skills practiced at the facility for those patients it is clinically indicated for. The Director of Clinical Services or Clinical Supervisor will provide oversight via random weekly chart audits. Any issues with compliance of regulation 709.53 will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |