INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on February 15, 2012, by staff from the Division of Drug and Alcohol 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of one hour per week of direct observation in one of five personnel records.
The findings include:
Five personnel records were reviewed during an administrative review on February 6, 2012. One record required the documentation of close clinical supervision, record # 5.
Employee # 5 was hired for their current position on 4/24/2011. The degree of a B.A. in Criminal Justice was verified. Employee # 5 had no clinical experience. Close supervision requires documentation of case review and an hour of direct observation weekly by a counselor or clinical supervisor. The documentation did not include direct observation of the counselor assistant.
The Facility Director was presented the findings on February 15, 2012. The findings were not disputed.
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Plan of Correction
The Director of Outpatient Services has been apprised that close supervision requires documentation of case review and an hour of direct observation weekly by a counselor or clinical supervisor. Any future oversight of staff requiring close supervision will include documentation that reflects an hour of direct observation. The Director of Outpatient Services will assume primary responsibility for this task. |
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
Based on the review of policy and procedures, the facility failed to have a procedure for the evacuation of staff and clients during an emergency.
The findings included:
An administrative review occurred on February 7, 2012. The procedures for emergencies was reviewed. The facility did not have a site specific procedure for evacuation.
The Facility Director confirmed on February 15, 2012 that they have no additional procedure policies.
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Plan of Correction
The facility is currently revising agency policy. The revision will reflect a site-specific procedure for the evacuation of staff and clients during an emergency. The revised policy will be completed on or before 3/31/12 and will become part of the general safety & emergency policies and procedures.
The Director of Outpatient Services will assume primary responsibility for this task and will monitor that it does not reoccur once it becomes part of the applicable policies and procedures. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a physical plant inspection, the facility failed to set off a fire alarm or smoke detector during fire drills.
The findings include:
On February 15, 2012 at approximately 9:45 a.m., during the physical plant inspection, a review of the fire safety was conducted. The facility does not set off a fire alarm or smoke detector during fire drills. The facility uses a sign shown to staff members at the time of the fire drill.
During an interview with the Facility Director, they described the process used for the drills.
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Plan of Correction
The facility intends to purchase an air horn to be sounded during monthly fire drills. This will be completed by March 21, 2012.
The Director of Outpatient Services will assume primary responsibility for this task and will monitor its implementation and ongoing practice.
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
The findings include:
An administrative review occurred on February 7, 2012. The letters of agreement were reviewed at that time. No letter of agreement regarding 24-hour emergency medical coverage was documented.
The Facility Director confirmed that they have no additional letters of agreement.
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Plan of Correction
The Risk Manager has obtained a letter of agreement with Waynesboro Hospital for 24-hour emergency medical coverage. This was completed on February 27, 2012.
The Risk Manager will perform annual reviews of referral agreements and will report findings annually to the Medical Executive Committee.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in five of six client records.
The findings included:
Ten client records were reviewed on February 15, 2012. Six of the client records reviewed required consent to release information. The facility failed to ensure that an informed and voluntary consent to release information was obtained in five records, # 5, 6, 8, 9 and 10.
A review of client record # 5 revealed information was released to a funding source without a documented consent on 12/20/2011.
A review of client record # 6 revealed information was released to a funding source without a documented consent on 7/18/2011 and 1/2/2012.
A review of client record # 8 revealed information was released to a funding source without a documented consent on 7/20/2011, 1/2/2012 and 2/2/2012.
A review of client record # 9 revealed information was released to a funding source without a documented consent on 9/27/2011, 1/2/2012 and 2/2/2012. In addition, a treatment contract was faxed to a probation officer on 1/18/2012. This documentation release was outside of the scope of Pa. Code 255.5 that includes the areas where disclosure is permitted.
A review of client record # 10 revealed information was released to funding source without a documented consent on 12/30/2011 and 1/3/2012.
The findings were reviewed with the Facility Director and not disputed.
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Plan of Correction
A consent to release information to the Pennsylvania Department of Public Welfare PROMISE Internet has been developed and said documentation will be routinely obtained for all clients for whom recipient eligibility verification is done electronically.
Staff have been notified as to the necessity of obtaining a Pennsylvania Department of Public Welfare consent and procedures have been modified. This was completed on March 2, 2012.
Additionally on 2/28/12, staff received clarification regarding the scope of areas permitted to be disclosed.
The Director of OP Services will monitor client records to ensure the new Pennsylvania Department of Public Welfare consent is being used and that staff are in compliance with areas of disclosure.
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709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of facility policy, a review of the client handbook, and a physical plant inspection, the facility failed to inform clients of their rights.
The findings include:
An administrative review of the facility's policy was completed on February 6, 2012. The facility's policy states clients will be informed of their rights via the Patient Bill of Rights, and displayed in the waiting room, lobby area and other areas frequented by persons receiving services.
On February 15, 2012 at approximately 9:45 a.m., during the physical plant inspection, a review of the posted information was completed. The facility did not display the patient rights.
On February 15, 2012, the client handbook was reviewed. The handbook did not include the Patient Bill of Rights.
The Facility Director was presented the findings. The findings were not disputed.
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Plan of Correction
The Director of OP Services has revised the patient handbook to include a copy of the patient's Bill of Rights. The patient's Bill of Rights has also been posted in the public areas of the outpatient offices. The revision and public posting was completed on 2/23/12.
The Risk Manager will review Patient Handbooks annually and will monitor and update Handbooks as needed when changes are required.
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709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document individualized progress notes in two of six records.
The findings included:
Ten client records were reviewed on February 15, 2012. Six of the client records were reviewed for progress notes. The facility failed to ensure that individualized progress notes were completed after each client contact in two client records, # 6, and 9.
Client # 6 was admitted on 8/1/2011. Progress notes were completed after each client contact that included data, assessment and plan. The assessment for each group progress note lacked documentation of the counselor's analysis and conclusions. In every documented group progress note the plan stated the client "will continue attending intensive outpatient substance abuse treatment. She will work on her treatment goals. (Client) will remain sober."
Client # 9 was admitted on 10/18/2011. Progress notes were completed after each client contact that included data, assessment and plan. The assessment for each group progress note lacked documentation of the counselor's analysis and conclusions. In every documented group progress note the plan stated the client will continue attending intensive outpatient substance abuse treatment, will work on the treatment goals and has remained sober.
The findings were reviewed with the Facility Director and not disputed.
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Plan of Correction
The Director of OP Services will facilitate a training with pertinent clinical staff on progress notes. This training will educate staff on the importance of writing individualized progress notes, in which the assessment portion reflects the counselor's clinical perspective. This training will be completed by March 31, 2012.
Furthermore, the Director of Outpatient Services will complete chart audits (as signified by initialing notes in random charts)to monitor compliance and report to the PI committee monthly. In instances where the progress note documentation lacks counselor analysis and conclusions, added supervision will occur until progress notes sufficiently reflect their clinical assessment of the client.
The Director of Outpatient Services will assume primary responsibility for this task and will monitor its implementation and ongoing practice. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of administrative documentation, the facility failed to comply with 55 Pa. Code Part III.
The findings included:
Administrative documentation reviewed on February 15, 2012 did not include a physician on staff to provide oversite for the management of Medical Assistance funded clients.
The findings were reviewed and confirmed by the Facility Director.
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Plan of Correction
The facility is committed to correct this deficiency and is currently in the process of recruiting a physician to provide oversight as required by 55 Pa. Code Part III.
The Project Director has completed interviews and a candidate has tentatively accepted the position. A start date is undetermined pending a signed contract; however the deficiency should be resolved on or before April 15, 2012.
It is the responsibility of the Chief Medical Officer to monitor the assigned physicians and fulfillment of their duties within the facility to ensure the deficiency does not recur.
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