INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 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 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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705.2 (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 a physical plant inspection, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:
A stairway in the rear of the building was not clear from snow/ice.
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Plan of Correction
The stairway was immediately cleared off and maintenance staff will be re-educated on ensuring that all walkways and stairways are cleared during inclement weather. The Director of Plant Operations will provide this re-education no later than 2/8/19. The Director of Plant Operations, or his designee, will provide oversight of these areas and report any issues found in the daily leadership team meeting. Staff will be re-educated, as necessary, throughout the monitoring process. |
705.7 (b) (2) 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:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure all food was stored off the floor. Milk and tea cartons were observed on the floor in the walk in and a box of rolls was stored on the floor of the dry stock area.
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Plan of Correction
The items found to be on the floor were immediately removed and placed on dry stock shelves and on shelving in the walk-in refrigerator. The Director of Plant Operations will provide re-education to all dietary staff by 2/8/19 on ensuring proper storage of food and drink items in the kitchen and associated areas. The Director of Plant Operations will ensure that daily assessment of proper food/drink storage is found on the dietary checklist and he, or his designee, will provide random weekly checks of the kitchen to ensure compliance. Results will be reported in a weekly leadership team meeting and staff will be re-educated, as necessary, throughout the monitoring process. |
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
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14.
A Consent for treatment and conditions of admission form in paragraph # 10 contains verbiage that states verbatim " I hereby authorize Roxbury and my physicians to release medical, psychiatric and "substance abuse" information contained in my/the patient's records to any necessary insurance carrier(s), and other representatives of legal and regulatory agency(s), (i.e. Joint Commission, AHCA & CMS) for the purpose of obtaining information and/or reviewing the record for quality and medical care received by the patient and for the payment of all hospital and medical charges" in 8 of 8 records reviewed.
A consent to release form allowing the release of psychiatric discharge summary/CC plan/DX page, psychological evaluation, educational information, psychiatric evaluation, consultations, history and physical, lab/radiology data, demographic information, and insurance information to local SCA organizations were located in client record #'s 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12.
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Plan of Correction
Both the Consent for Treatment/Conditions of Admission form and the SCA release of information have been revised to meet the confidentiality requirements of PA Code 255.5 regarding releases of information. Admissions staff will be re-educated by 2/8/19 on ensuring that all releases of information are in compliance with PA Code 255.5. The Director of Admissions will provide random weekly checks of releases to ensure compliance and any issues will be reported in the weekly leadership team meeting. Staff will be re-educated, as necessary, throughout the monitoring process. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to provide documentation of termination letters and the opportunity for clients to request reconsideration of a decision to terminate.
Client # 15 was admitted on November 5, 2017 and was therapeutically discharged on November 14, 2017.
Client # 16 was admitted on February 23, 2017 and was therapeutically discharged on March 13, 2017.
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Plan of Correction
A termination letter that meets regulation 709.33 has been developed by the Director of Clinical Services for use with any patients being discharged therapeutically. Clinical staff will be educated by 2/8/19 on the use of this document by the Director of Clinical Services and/or the Clinical Supervisor. The Director of Clinical Services and/or the Clinical Supervisor will review 100% of therapeutic discharges to ensure compliance. Results will be reported in leadership team meetings and staff will be re-educated as necessary throughout the monitoring process. |