INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22, 2021 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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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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client record # 5.
Client # 5 was admitted on March 30, 2020 and was discharged on July 2, 2020. There was not an informed and voluntary consent from the client for the disclosure of information for a funding source. A review of the client record indicated a funding source for the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were re-educated on not only the standard of receipt of all informed and voluntary consents but as to the requirement of specific consents such as disclosure of information for a funding source.
Ongoing weekly, random file audits will occur that the Project Director will supervise and track. Results will be presented at weekly staff meetings and/or monthly staff supervisions with re-education as necessary throughout the monitoring process.
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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 five of six client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and updated at least every 60 days.
Client # 1 was admitted on September 2, 2020 and was still active at the time of the inspection. A treatment plan update was due to be completed on March 14, 2021. The last treatment plan update occurred on January 14, 2021.
Client # 2 was admitted on January 5, 2021 and was discharged on March 15, 2021. A treatment plan update was due to be completed on March 13, 2021. The last treatment plan update occurred on January 13, 2021.
Client # 4 was admitted on September 17, 2020 and was still active at the time of the inspection. A treatment plan update was due to be completed on November 21, 2020 and January 21, 2021. The last treatment plan update occurred on September 21, 2020.
Client # 6 was admitted on May 27, 2020 and was discharged on August 4, 2020. A treatment plan was developed on May 27, 2020. A treatment plan update was due to be completed on July 27, 2020.
Client # 7 was admitted on March 24, 2020 and was discharged on September 30, 2020. A treatment plan update was due to be completed on July 15, 2020 and September 15, 2020. The last treatment plan update occurred on May 15, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors were re-educated on providing documentation of treatment and rehabilitation plans being reviewed and updated at least every 60 days; also ensuring they understand the date is from client signature.
Ongoing weekly, random file audits will occur that the Project Director will supervise and track. Results will be presented at weekly staff meetings and/or monthly staff supervisions with re-education as necessary throughout the monitoring process.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on three of seven client records reviewed, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in client records # 4, 6, and 7.
Client # 4 was admitted on September 17, 2020 and was still active at the time of the inspection. A treatment plan developed on September 21, 2020 indicated IOP sessions three times a week. A review of progress notes and record of service indicate group sessions did not occur three times a week. The month of September 21-October 21 indicated 4 group sessions, October 21-November 21 indicated 6 group sessions, November 21-December 21 indicated 5 group sessions, December 21-January 21- indicated 10 group sessions, January 21- February 21 indicated 9 group sessions, February 21-March 4 indicated 4 group sessions.
Client # 6 was admitted on May 27, 2020 and was discharged on August 4, 2020. A treatment plan developed on May 27, 2020 indicated IOP sessions two times a week plus one individual. A review of progress notes and record of service indicate no group sessions were documented in the client record.
Client # 7 was admitted on March 24, 2020 and was discharged on September 30, 2020. A treatment plan developed on April 1, 2020 indicated IOP sessions three times a week. A review of progress notes and record of service indicate group sessions did not occur three times a week. The month of April 1- May 1 indicated 7 group sessions, May 1- June 1 indicated 7 group sessions, June 1- July 1 indicated 2 group sessions, July 1- August 1 indicated 0 group sessions, August 1- September 1 indicated 0 group sessions.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 1, 2019 inspection.
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Plan of Correction
All counselors were re-educated on the importance of ensuring that treatment plans were updated and reflective of the level of care/ frequency of service that the client is receiving.
Ongoing weekly, random file audits will occur that the Project Director will supervise and track. Results will be presented at weekly staff meetings and/or monthly staff supervisions with re-education as necessary throughout the monitoring process.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on three of seven client records reviewed, the facility failed to provide a complete client record to include a record of services provided in client records # 2, 5,and 6.
Client # 2 was admitted on January 5, 2021 and was discharged on March 15, 2021. A review of the client record and progress notes indicated group sessions occurred on January 13, 21, 28, February 5,11, 25, March 4, and 11, 2021. There was no record of service provided in the client record.
Client # 5 was admitted on March 30, 2020 and was discharged on July 2, 2020. A review of the client record and progress notes indicated group sessions occurred on April 22, 23, 27, 29, May 1, 4, 7, 20 and 29. There was no documentation of these services on the record of service.
Client # 6 was admitted on May 27, 2020 and was discharged on August 4, 2020. A review of the client record and progress notes indicated individual sessions occurred on June 16, 2020. There was no documentation of these services on the record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors were re-educated on the importance of ensuring services delivered were not just documented on billing slips and progress notes, but on a record of service as well.
Ongoing weekly, random file audits will occur that the Project Director will supervise and track. Results will be presented at weekly staff meetings and/or monthly staff supervisions with re-education as necessary throughout the monitoring process.
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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 four of four applicable client records reviewed, the facility failed to provide a complete client record to include case consultation notes in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate case consultations to occur at least once during treatment.
Client # 2 was admitted on January 5, 2021 and was discharged on March 15, 2021. There was no documentation of a case consultation in the client record.
Client # 5 was admitted on March 30, 2020 and was discharged on July 2, 2020. There was no documentation of a case consultation in the client record.
Client # 6 was admitted on May 27, 2020 and was discharged on August 4, 2020. There was no documentation of a case consultation in the client record.
Client # 7 was admitted on March 24, 2020 and was discharged on September 30, 2020. There was no documentation of a case consultation in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure will be reviewed surrounding case consultations and all counselors will be educated upon completion.
Ongoing weekly, random file audits will occur that the Project Director will supervise and track. Results will be presented at weekly staff meetings and/or monthly staff supervisions with re-education as necessary throughout the monitoring process.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on three of four applicable client records reviewed, the facility failed to provide a complete client record to include a discharge summary in client records # 5, 6, and 7.
Client # 5 was admitted on March 30, 2020 and was discharged on July 2, 2020. There was no documentation of a discharge summary in the client record.
Client # 6 was admitted on May 27, 2020 and was discharged on August 4, 2020. There was no documentation of a discharge summary in the client record.
Client # 7 was admitted on March 24, 2020 and was discharged on September 30, 2020. There was no documentation of a discharge summary in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will be re-educated on the important of including a discharge summary not just in creation but also present in each client record upon discharge.
Ongoing weekly, random file audits will occur that the Project Director will supervise and track. Results will be presented at weekly staff meetings and/or monthly staff supervisions with re-education as necessary throughout the monitoring process.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on three of four applicable client records reviewed, the facility failed to provide a complete client record to include follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate follow-up information for referrals to be a phone call within one week and non-referrals to be within three months by letter.
Client # 5 was admitted on March 30, 2020 and was discharged on July 2, 2020. There was no documentation of a follow-up in the client record.
Client # 6 was admitted on May 27, 2020 and was discharged on August 4, 2020. There was no documentation of a follow-up in the client record.
Client # 7 was admitted on March 24, 2020 and was discharged on September 30, 2020. There was no documentation of a follow-up in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors were re-educated to ensure a copy of the follow up letter that is sent also be placed into the client file.
Ongoing weekly, random file audits will occur that the Project Director will supervise and track. Results will be presented at weekly staff meetings and/or monthly staff supervisions with re-education as necessary throughout the monitoring process.
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