INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 3, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Roxbury was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 facility was clean, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The following was observed:
-dirt and debris on steps leading from basement to first floor
- lint, dirt, and debris in men ' s laundry room
- q tip and trash in men ' s inpatient hallway
- dirt, lint and debris on floor in women's laundry room
- unwrapped cough drop and other trash on the floor of detox room #27
- chipped floor tile in room # 2
- dirt and trash on the floor in group room A
- dust caked on three ceiling vents in group room A
- dirt and crumbs on the floor in the doctor ' s office
- cracked/chipped tile in hallway leading from main lobby room to cafeteria
-baseboard missing from last shower stall of men ' s second bathroom on right side of hall
-cracked, warped wall with chipped paint in men ' s bathroom on left side of hall
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Plan of Correction
All the bathrooms in the male rehab hallway are in the process of being re-modeled. A contractor was hired but waiting for them to start.
Vents in group room were cleaned the day of the inspection by staff. Staff then cleaned all vents on unit within several days of visit.
Director of Plant Operations re-educated housekeeping staff on the importance of following the cleaning schedule. All bedrooms in the detox wing and rehab wing have been cleaned by staff. Laundry rooms were also cleaned.
Will continue to monitor cleaning schedule to ensure all required cleaning is being done. Monitoring will continue until 3/24/24. We had a licensing visit this week and received no citations in plant operations.
Director of Plant Operations and Risk Manager complete environment of care (EOC)rounds monthly and report findings quarterly in EOC committee. Director of Plant Operations is responsible for any corrective action (s) in this area. |
705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection, the facility failed to maintain counseling areas with furnishings which are in good repair.
It was observed that four chairs in group room A had holes and cracks in the leather-like material.
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Plan of Correction
Director of Plant Operations ordered new chairs and chair parts to replace ripped chair backs. These will be replaced as soon as the chairs and the chair parts come in. Will be replaced by 5/31/2024. The chair parts are ordered but take 3-4 months to arrive.
Director of Plant Operations will be responsible for ensuring the corrective actions are implemented.
The four chairs in group room A have been removed. Director of Plant Operations will continue to monitor this through monthly environment of care rounds. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection, the facility failed to supply a fire retardant mattress in good repair.
It was observed that room # 2 contained two mattresses with cracking on the outside vinyl material. These mattresses also appeared to be sagging in the middle and higher, with more padding, on the ends.
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Plan of Correction
Director of Plant Operations was notified of this finding and the mattresses in this room were replaced on 1/19/2024.
The Director of Plant Operations and Risk Manager will complete monthly environment of care rounds to ensure that this does not reoccur. Finding from EOC rounds will be discussed as a team and deficient items will be replaced in a timely manner. Director of Plant Operations will be responsible for ensuring corrective action is implemented. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of client charts and other administrative documentation, the facility failed to inform the Department of physical assaults that occurred at the facility within the required three business days.
Documentation was discovered that physical assaults by clients occurred at the facility on 7/8/23 and 10/31/23.
These incidents were not reported to the Department.
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Plan of Correction
The Director of Performance Improvement (DPI) is responsible for this task. There was a change in position in June 2023, and the new DPI was not aware of this responsibility. DDAP inspector educated DPI on this duty and provided several handouts on how and when to do unusual incident reports. DPI is now aware and has made two reports since this inspection. Re-education was provided by DDAP on 1/3/2024. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client charts and other administrative documentation, the facility failed to inform the Department of events at the facility requiring the presence of police and ambulance personnel within the required three business days.
Pennsylvania State Police were at the facility on 11/20/23.
Ambulance personnel were at the facility on 6/2, 6/19, 7/11, 7/15, 7/29, 8/11, 10/18, 10/30, 11/22, 12/15, 12/16, 12/21, 12/23, and 12/26/23.
These incidents were not reported to the Department.
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Plan of Correction
The Director of Performance Improvement (DPI) is responsible for the reporting of unusual incidents. There was a change in position in June 2023, and the new DPI was not aware of this responsibility. DDAP inspector educated DPI on this duty and provided several handouts on how and when to do unusual incident reports. DPI is now aware and has made two reports since this inspection. Re-education was provided by DDAP on 1/3/2024. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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 a review of client charts, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in three of four charts reviewed.
Client #2 was admitted on 11/1/23 and discharged on 11/22/23. The treatment plan, dated 11/3/23, indicated one individual session per week. The progress notes indicated that the client did not receive an individual session the weeks of 11/5/23 and 11/12/23.
Client # 3 was admitted on 10/6/23 and discharged on 11/20/23. The treatment plan, dated 10/7/23, indicated one individual session per week. The progress notes indicated that the client did not receive an individual session the weeks of 10/15/23, 10/22/23, 10/29/23, 11/5/23 and 11/12/23.
Client # 4 was admitted on 12/6/23 and discharged on 12/28/23. The treatment plan, dated 12/10/23, indicated one individual session per week. The progress notes indicated that the client did not receive an individual session the weeks of 12/10/23 and 12/17/23.
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Plan of Correction
The Clinical Supervisor, or her designee, will complete weekly chart audits to ensure that all individual sessions are completed per policy and in the required timeframe. Continued education will occur, as necessary, throughout the monitoring process, audit results will be reported monthly through the Performance Improvement Committee. First audit will be due by 2/29/2024. |