INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 2025 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in one out of three employee records reviewed. The facility's policy is to complete a training plan at the time of an employees hire and then annually by the anniversary of the employees hire date.
Staff #1 was hired on February 5, 2024, as the project/facility director and was still in the position as of the date of the inspection. There was no documentation that a training plan was completed for this staff.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Director of Performance Improvement will provide education to the Director of Human Resources and the Director of Outpatient on the requirements of the training plan for staff members. Staff #1 signed a training plan; this was placed in the employee file. The Director of Human Resources, or designee will ensure all new employees receive and sign a training plan within the New Hire Orientation. The Director of Human Resources, or designee will monitor the training plans through a tracking process and ensure direct supervisors have ongoing communication regarding training plan due dates to maintain compliance. The Director of Human Resources will forward data to the Performance Improvement Committee Quarterly until continued compliance is sustained. |
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 facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #2 was hired as a counselor on September 11, 2023, and was due to have the communicable disease trainings no later than September 11, 2024. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #3 was hired as a counselor on October 9, 2023, and was due to have the communicable disease trainings no later than October 9, 2024. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
The Director of Performance Improvement will provide one to one education the Director of Human Resources and the Director of Outpatient Services on the regulation. Employee #2 and Employee #3 will be scheduled for the next available virtual open TB/STD training. Immediately following the training, Employee #2 and Employee #3 will forward the certificate to both, the Director of Outpatient and the Director of Human Resources to ensure follow up and completion. The Director of Human Resources, or designee will monitor the required training dates of TB/STD and HIV/AIDS through a tracking process and ensure direct supervisors have ongoing communication regarding training due dates to maintain compliance. The Director of Human Resources will forward data to the Performance Improvement Committee Quarterly until continued compliance is sustained. |
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 2024 - December 2024, 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: February, April, May, June, August, September, October, November and December of 2024.
This is a repeat citation from the January 22, 2024, annual licensing inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Performance Improvement has provided a one-to-one education to the Director of Outpatient Services and the Director of Plant Operations on the requirements of Fire Drills. A one-time Fire Drill has been completed on-site. The Director of Outpatient will ensure that the Fire Drills are completed monthly per the requirements of the regulation. The Director of Outpatient Services will forward data to the Performance Improvement Committee monthly until continued compliance is sustained. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in three out of seven client records reviewed.
Client #1 was admitted on November 11, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was developed on December 19, 2024 with no treatment type documented.
Client #2 was admitted on September 19, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 24, 2024, with no treatment type documented.
Client #7 was admitted on August 21, 2024, and discharged on December 19, 2024. A comprehensive treatment plan was developed on August 29, 2024, with no treatment type documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Performance Improvement will provide a one-to-one education to the Director of Outpatient on the requirements of an individual treatment plan for all active patients, focusing on documentation on treatment type. The Director of Outpatient will review and update the treatment plan type for Client #1, Client #2 and Client #7. The Director of Outpatient Services will provide one to one education to all Outpatient staff members on the requirements of an individual treatment plan for all active patients, focusing on documentation on treatment type. The Director of Outpatient, or designee will complete an audit of 100% of active patient treatment plans to ensure documentation of treatment type. The Director of Outpatient will perform monthly audits of active patient charts to ensure documentation of active patient type is on the treatment plan. The Director of Outpatient will forward data to the Performance Improvement Committee monthly until continued compliance is sustained. |