INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on February 15, 2013, 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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709.14(a) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
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Observations
Based on administrative documentation and the review of client census information, the facility failed to comply with the maximum approved capacity for the outpatient treatment activity.
The findings included:
The Staffing Requirements Facility Summary Report and the active client list were reviewed. The Report and the active client list confirmed a census of 57 when the capacity for the outpatient activity was 50.
This finding was confirmed by the Facility Director.
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Plan of Correction
A letter was prepared by the Facility Director requesting that the capacity to provide outpatient drug-free services be increased from 50 to 70. The letter was faxed on February 18, 2013 to Ronald Young, Acting Director, with the original to follow by US postal service. The facility has grown from the time of original licensure and has sufficient full-time therapists and space to accommodate the increased census. Until approval for the capacity increase is received, the facility has placed a hold on all new admissions until the census drops below the currently licensed capacity. The Facility Director will routinely monitor the active client list on a daily basis going forward to maintain compliance with the maximum approved capacity. |