INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24, 2024, 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from January 2023 - December 2023, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of May, June and July 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Plant Operations was informed immediately of this citation. Re-education was provided to the Director of Plan Operations on the requirements of fire drills. DPO will ensure monthly fire drills are completed and complete quarterly audits of this. Audit results will be reported to EOC Committee quarterly. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in three out of seven client records reviewed.
Client #1 was admitted on July 17, 2023 and was discharged on December 14, 2023. There was no documentation that a copy of an informed and voluntary consent to release information form for a medical provider dated July 17, 2023 was offered to the client.
Client #2 was admitted on March 13, 2023 and discharged on May 17, 2023. There was no documentation that a copy of an informed and voluntary consent to release information form for a funding source dated April 6, 2023 was offered to the client.
Client #4 was admitted on April 11, 2023 and was discharged on June 29, 2023. There was no documentation that a copy of an informed and voluntary consent to release information form for a medical provider dated April 11, 2023 was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
At the time of the finding, the Interim Outpatient Director met with all staff and provided a re-education on the completion on consents on 1/24/2024. Staff signed an attestation form. The Outpatient Director, or designee, will complete monthly chart audits to ensure compliance, and will report the results to the Performance Improvement committee monthly. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #2 was admitted on March 13, 2023 and discharged on May 17, 2023. A treatment plan was completed on March 13, 2023 and the next update was due no later than May 13, 2023; however, there is no documentation that an update occurred.
Client #3 was admitted on March 23, 2023 and discharged on December 11, 2023. A treatment plan was completed on April 4, 2023 and the next update was due no later than June 4, 2023; however, it was not completed until August 10, 2023. The next treatment plan update was due no later than October 10, 2023; however, it was not completed until October 12, 2023.
Client #4 was admitted on April 11, 2023 and discharged on June 29, 2023. A treatment plan was completed on April 26, 2023 and the next update was due no later than June 26, 2023; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Interim Outpatient Director provided a re-education to all staff on 1/24/2024 regarding the importance of completing treatment plan reviews per policy and in the required time frame. Continued re-education will occur as needed. The Outpatient Director, or designee, will complete monthly chart audits to ensure treatment plans are being completed per policy and will report the results to the Performance Improvement Committee monthly. |