INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 13, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using Department approved curriculum within the regulatory timeframe in two out of two records reviewed.
Employee #1 was hired as the project director/facility director/clinical supervisor on February 05, 2024, and was due to have the communicable disease training no later than February 05, 2025. There was documentation of the completion of the TB/STD training; however, it was not completed until January 08, 2026.
Employee #2 was hired as a counselor on December 03, 2024, and was due to have the communicable disease training no later than December 03, 2025. There was documentation of the completion of the HIV/AIDS training; however, it was not completed until January 08, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
A.Employee #1and Employee #2 completed training.
B.The Director of Performance Improvement will provide education to the Director of Human Resources and the Director of Outpatient Services on the requirements of Mandatory Communicable Disease training.
MONITORING:
A.The Director of Human Resources, or designee will monitor the required training dates monthly on TB/STD and HIV/AIDS through a tracking process to maintain compliance.
All data will be reported monthly through performance improvement committee with appropriate actions taken, up to and including discipline, for any continued noncompliance.
RESPONSIBLE: Director of Human Resources
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on review of client records, the facility failed to obtain a informed and voluntary consent form which included the specific information to be disclosed in one out seven records reviewed.
Client #2 was admitted on May 20, 2025, and was still active at the time of the inspection. A release of information form for county probation was signed and dated by the client on May 20, 2025; however, it did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
ACTIONS:
A. A new consent was obtained on 2/5/2026 for Client #2 to denote what specific information is to be disclosed at the patient's next scheduled outpatient appointment.
B. The Director of Performance Improvement provided education to the Director of Outpatient Services on 2/9/2026 on the requirements of confidentiality, focusing on completion of consents of the specific information disclosed.
C. The Director of Outpatient Services will provide one-to-one education to all outpatient counselors on 2/10/2026 on the requirements of confidentiality focusing on completion of consents and information that is being disclosed.
MONITORING:
A. The Director of Outpatient Services will complete a one-time audit of 100% of all active client consent to ensure the purpose of disclosure is specified.
B. The Director of Outpatient Services will complete a monthly audit of 100% of all active client consent to ensure the purpose of disclosure is specified.
All data will be reported monthly through performance improvement committee with appropriate actions taken, up to and including discipline, for any continued noncompliance.
RESPONSIBLE: Director of Outpatient Services
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information to be completed monthly, per facility policy, in seven out of seven records reviewed.
Client #1 was admitted on September 22, 2025 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client #2 was admitted on May 20, 2025 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client #3 was admitted on May 30, 2025 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client #4 was admitted on April 16, 2025 and was discharged on September 03, 2025. There was no documentation of case consultation information in the record.
Client #5 was admitted on May 26, 2025, and was discharged on July 11, 2025. There was no documentation of case consultation information in the record.
Client #6 was admitted on April 10, 2025, and was discharged on July 02, 2025. There was no documentation of case consultation information in the record.
Client #7 was admitted on April 21, 2025, and was discharged on August 11, 2025. There was no documentation of case consultation information in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
A. Client #1, Client #2, Client #3 are current clients and have a completed case consultations on 2/9/2026. Client #4, Client #5, Client #6, and client #7 have been discharged.
B.The Director of Performance Improvement provided education to the Director of Outpatient Services on 2/9/2026 on the requirements of Client Records.
C. The Director of Outpatient Services provided a one-to-one education to Outpatient counselors on 2/10/2026 on the requirements of the client records.
MONITORING:
A. The Director of Outpatient Services will complete a one-time audit of 100% of active client charts to ensure the client record includes case consultation notes.
B. The Director of Outpatient Services will complete a monthly audit of 100% of active client charts to ensure the client record includes case consultation notes.
All data will be reported monthly through performance improvement committee with appropriate actions taken, up to and including discipline, for any continued noncompliance.
RESPONSIBLE: Director of Outpatient Services
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