INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Roxbury Chambersburg 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
The facility failed to provide documentation of fire drills being conducted on different days of the week. Fire drills were recorded to have occurred on Tuesday the months of November 2017, January, February, April, May, July, August, and October 2018 and to have occurred on Mondays the months of December 2017, March, June, and September 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Outpatient Services received re-education on ensuring that fire drills are staggered and occur in compliance with regulation 705.28(d). The Director of Plant Operations will coordinate with the Director of Outpatient Services and provide oversight to ensure compliance via monthly checks. Any issues will be reported in the leadership team meeting. Staff will be re-educated, as necessary, throughout the monitoring process. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility ' s Policy and Procedure for the management of treatment/rehabilitation services for clients states that a treatment plan will be developed with the client within 72 hours of admission. The facility failed to provide documentation that this was completed in 2 of 7 records reviewed.
Client # 1 was admitted on December 4, 2018 and was still an active client at the time of the inspection. A treatment plan was not developed with the client until January 2, 2019.
Client # 3 was admitted on October 4, 2018 and was still an active client at the time of the inspection. A treatment plan was not developed with the client until October 22, 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
It was determined that 72 hour timeframe for treatment plan initiation found in the Treatment Planning policy was incorrect for the outpatient and intensive outpatient treatment levels of care. The Treatment Planning Policy, specific to outpatient services, has been revised to include the accurate and appropriate timeframes for both initiation and update of the treatment plan. Staff will receive re-education on the new policy and timeframes during team meetings and competency will be assessed via attestation and through chart audits. The Director of Outpatient Services, or designee, will provide oversight on ensuring treatment plan timeframes are met. Compliance will be evaluated by the Director of Outpatient Services on a weekly basis via chart audits and any ongoing issues or trends will be reported in the weekly leadership team meeting. Staff will be re-educated, as necessary, throughout the monitoring process. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to ensure that there was appropriate documentation of written acknowledgment by the client, that the client had been made aware of their rights in client record # ' s 1, 2, 3, 4, 5, 6, and 7. The clients rights provided to the client was missing the verbiage "creed, ethnicity, national origin, marital status, sexual orientation, and handicap. "
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Patient Handbook/Client Rights Notification for outpatient services has been revised to include the verbiage regarding non-discrimination of patients in accordance with regulation 709.30(1). The Director of Outpatient Services, or designee, will provide re-education to staff and perform random weekly checks to ensure compliance. Any issues will be reported in the weekly leadership team meeting. Staff will be re-educated, as necessary, throughout the monitoring process. |
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
The facility failed to provide documentation that the clients received Individual counseling services according to their individual comprehensive treatment plan in 7 of 7 charts reviewed.
Client # 1 was admitted on December 4, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan dated January 2, 2019 indicated 1 individual session weekly. The chart's record of service and progress notes indicated that the client had only received individual sessions on November 12 and December 4, 2018.
Client # 2 was admitted on January 21, 2019 and was still an active client at the time of the inspection. The comprehensive treatment plan dated January 28, 2019 indicated 1 individual session weekly. The chart's record of service indicated that the client had only received individual sessions on January 21, 2019.
Client # 3 was admitted on October 4, 2018 and was still an active client at the time of the inspection. The comprehensive treatment plan dated October 22, 2018 indicated 1 individual session weekly. The chart's record of service and progress notes indicated that the client had only received individual sessions on September 24, 2018 and October 4, 2018.
Client # 4 was admitted on January 8, 2019 and was still an active client at the time of the inspection. The comprehensive treatment plan dated October 22, 2018 indicated 1 individual session weekly. The chart's record of service and progress notes indicated that the client had only received individual sessions on December 4, 2018 and January 8, 2019.
Client # 5 was admitted on August 21, 2018 and was discharged on October 16, 2018. The comprehensive treatment plan dated August 28, 2018 indicated 1 individual session weekly. The chart's record of service and progress notes indicated that the client had only received individual sessions on August 9 and August 21, 2018.
Client # 6 was admitted on April 23, 2018 and was discharged on June 19, 2018. The comprehensive treatment plan dated August 28, 2018 indicated 1 individual session weekly. The chart's record of service and progress notes indicated that the client had only received individual sessions on April 23, 2018.
Client # 7 was admitted on June 5, 2018 and was discharged on November 13, 2018. The comprehensive treatment plan dated August 28, 2018 indicated 1 individual session weekly. The chart's record of service and progress notes indicated that the client had only received individual sessions on June 5 and July 17, 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The treatment plan forms were revised to include specifics with regard to the required frequency of individual sessions. The Director of Outpatient Services, or designee, will provide re-education to staff during team meetings and competency will be assessed via attestation and through chart audits. The Director will also provide oversight on compliance of patients receiving all necessary services, including individual sessions, as laid out by their treatment plan. Compliance will be evaluated on a weekly basis via chart audits and any ongoing issues or trends will be reported in the weekly leadership team meeting. Staff will be re-educated, as necessary, throughout the monitoring process. |