INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 27, 2011 by staff from the Division of Drug and Alcohol 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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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, incident reports and a client interview, the facility failed to report an unusual incident in accordance with facility policy and procedure and Division directives addressed in Licensing Alert 5-97.
The findings include:
A complaint investigation was conducted on September 27, 2011. On the evening of September 13, 2011 altercations between several residential patients took place. A fight broke out and a resident was injured as a result. A client who was assaulted during the incident was interviewed on September 27, 2011 and confirmed that the incident took place. The facility failed to report the incident in accordance with facility policy and procedure and and further failed to submit an incident report to the Division of Drug and Alcohol Program Licensure within 72 hours using the Division's Unusual Incident Report Form (Form #HD1062F).
Facility policy and procedure states: " Roxbury Treatment Center is committed to risk prevention which promotes early identification, assessment, and intervention of any occurrences. This policy is to provide a method of reporting and reviewing any unusual incident such as injury to a patient, visitor or staff member; Or an occurrence such as fire, which threatens the health and safety of a patient, visitor, staff member or the environment at Roxbury Treatment Center. To ensure documentation, review and reporting of unusual incident."
The facility's procedure specifies the following::
"1. Occurrence Reporting Treatment center utilizes the Corporate approved occurrence report form (Healthcare Peer Review Form _ HPR) for reporting occurrences. "
" 3. The Risk Manager utilizes the Probable Claim Report to report patient occurrences resulting in death, injury, or potential injury to patients and/or with potential for claim."
An interview conducted with the Risk Manager and the Director of Performance Improvement and Staff Development on September 27, 2011 confirmed the findings.
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Plan of Correction
The policy of Roxbury Treatment Center is to report unusual incidents utilizing the Corporate approved occurrence report form (Healthcare Peer Review Form-HPR) for reporting occurrences. The Risk Manager reports unusual occurrences to the Pennsylvania Safety Authority via PASRS reporting system. Occurrences are also reported to individual insurance companies as required. The Risk Manager has obtained appropriate reporting form from the Department of Health for reporting of unusual occurrences and will report such occurrences when they arise. When an unusual incident occurs, the Risk Manager will complete the "Unusual Incident Form" as required by the Department of Health and submit the required form via fax to the Department of Health in accordance to licensing alert 5-97. This form was implemented on October 10, 2011. The Risk Manager will monitor the number of unusual occurrences and will report the findings quarterly to the Performance Improvement Committee. |
709.24(a)(4) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers.
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Observations
Based on a review of client records, client interview and the facility's policy and procedure, the facility failed to ensure that the client was safe from harm and injury.
The findings include:
A complaint investigation was conducted on September 27, 2011. On the evening of September 13, 2011 altercations between several residential patients took place. A fight broke out and a resident was injured as a result. A client who was assaulted during the incident was interviewed on September 27, 2011 and confirmed that the incident took place. The client interviewed also confirmed that one client did report that he was afraid to stay and left the facility only to return to the Intake Department on facility grounds.
Staff was also interviewed on September 27, 2011 and confirmed the findings. Staff interviewed stated that the client did leave and returned back to the facility but went to the Intake Department instead of the unit. The staff stated that the client was saying that he was afraid to come back on the unit and wanted to be transferred. The client was not transferred and the next morning left against facility advice.
The policy name: Patient Rights and Responsibilities
Effective date: 1/15/04
Policy: The Roxbury Center shall support and protect the fundamental human, civil, constitutional and statutory rights of the individual patient, foster the individual's right to participate in their own care, and recognize and respect personal dignity of the patient at all times.
Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned.
Transfer and Continuity of Care: A patient may not be transferred to another facility unless he/she has received a complete explanation of the need for the transfer and of the alternative to such a transfer and unless the transfer is acceptable to the other facility. The patient has the right to be informed by the practitioner responsible for his/her care, or his/her delegate of any continuing health care requirements following discharge from the hospital.
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Plan of Correction
It is the policy of Roxbury Treatment Center to support and protect the fundamental human, civil, constitutional and statutory rights for the individual patient, to foster the individual's right to participate in their own care and to recognize and respect personal dignity of the patient at all times. When a situation occurs that a patient requests a transfer to another facility, all efforts will be made to ensure the immediate safety of the patient and all attempts will be made to have the patient remain in treatment. The initial debriefing will be completed by a counselor aide and/or nurse. The counselor aide and/or nurse will notify the patient's counselor who will then meet with the patient to discuss the situation and options available as soon as feasibly possible after the request for transfer is made. If after the debriefing, the patient is still requesting a transfer, all efforts will be made to facilitate the transfer. The DCS and/or Clinical Supervisor will be made aware of the patient's request to transfer and will assist in facilitation of the transfer. DCS and/or Clinical Supervisor will be made aware of all requests for transfers to ensure appropriate action is taken. The DCS will develop a form that will be completed by the patient's counselor upon initial request for transfer. The Medical Executive Committee will approve of the newly implemented form prior to 11/18/11. The Clinical Supervisor is responsible for tracking all requests for transfers and the outcomes of the requests and will report the findings quarterly to the Performance Improvement Committee. The DCS and/or Clinical supervisor will re-educate clinical staff on the procedure for requests for transfers/referrals and implementation of tracking form and prior to 11/25/11.
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709.30(1) LICENSURE Client Rights
709.30. Client rights.
(1) A person receiving care or treatment under section 7 of the act (71 P. S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, client interview and the facility's policy and procedure, the facility failed to ensure that the client was safe from harm and injury.
The findings include:
A complaint investigation was conducted on September 27, 2011. On the evening of September 13, 2011 altercations between several residential patients took place. A fight broke out and a resident was injured as a result. A client who was assaulted during the incident was interviewed on September 27, 2011 and confirmed that the incident took place. The client interviewed also confirmed that one client did report that he was afraid to stay and left the facility only to return to the Intake Department on facility grounds.
Staff was also interviewed on September 27, 2011 and confirmed the findings. Staff interviewed stated that the client did leave and return back to the facility but went to the Intake Department instead of the unit. The staff stated that the client was saying that he was afraid to come back on the unit and wanted to be transferred. The client was not transferred and the next morning left against facility advice.
The policy name: Patient Rights and Responsibilities
Effective date: 1/15/04
Policy: The Roxbury Center shall support and protect the fundamental human, civil, constitutional and statutory rights of the individual patient, foster the individual's right to participate in their own care, and recognize and respect personal dignity of the patient at all times.
Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned.
Transfer and Continuity of Care: A patient may not be transferred to another facility unless he/she has received a complete explanation of the need for the transfer and of the alternative to such a transfer and unless the transfer is acceptable to the other facility. The patient has the right to be informed by the practitioner responsible for his/her care, or his/her delegate of any continuing health care requirements following discharge from the hospital.
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Plan of Correction
It is the policy of Roxbury Treatment Center to support and protect the fundamental human, civil, constitutional and statutory rights for the individual patient, to foster the individual's right to participate in their own care and to recognize and respect personal dignity of the patient at all times. When staff is made aware of a potential situation that would affect patient or milieu safety, immediate steps will be taken to ensure safety to include the following: The patient will initially meet with counselor aide and/or nurse who will evaluate the patient's concern. The counselor aide and/or nurse will notify the patient's counselor of the concern who will then meet with the patient to discuss the situation and options available as soon feasibly possible. The DCS and/or Clinical Supervisor or Administrator on Call will be made aware of the patient's concern and will assist in resolution of the patient's concern. The following are a list of possible solutions to patient safety concerns depending on the severity of the concern: room change, blackout status, 1:1 supervision, change in unit, change in core group, therapeutic contract, special precautions and transfers to another facility. Patient safety is ensured by every 30 minute observation rounds and increased monitoring will take place as needed. All issues concerning patient safety will be reported on the daily pass down report to heighten staff awareness while completing observation rounds. Any new precautions identified will be noted on the observation round form. The DCS is responsible for developing a form to be completed by a patient's counselor to address safety concerns. The safety concern form will be approved by the Medical Executive Committee prior to 11/18/11. The Clinical Supervisor is responsible for the tracking of safety concern forms and will report the findings quarterly to the Performance Improvement Committee. Re-training for counselor aides was completed by DCS on 10/12/11 on observation rounds, documentation, and supervision of patients. Re-education for counselor aide and clinical staff will be completed by the DCS and/or Clinical Supervisor to include resolving patient safety concerns, implementation of safety concern forms and milieu management by 11/25/11. |
709.32(c)(5) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(5) Security of drugs.
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Observations
Based on a review of client records, client interview and the facility's policy and procedure, the facility failed to ensure the security of all drugs on the premises.
The findings include:
A complaint investigation was conducted on September 27, 2011. On the evening of September 13, 2011, alleged altercations between several residential patients were confirmed to have taken took place. A fight broke out and a resident was injured as a result. A client who was assaulted during the incident was interviewed on September 27, 2011 and confirmed that the incident took place.
Staff interviewed on September 27, 2011 confirmed the findings. The staff interviewed stated that one client did inform him that he brought drugs into the facility and was using them. The client also informed the staff that there were other clients who were taking the drugs but that he would not mention who was taking them. As a result of this patient report, searches searches were conducted on clients who might have been involved with drug use. Reportedly, this was an issue that led to the altercation between several clients occurred and caused disturbance in the community.
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Plan of Correction
It is the policy of Roxbury Treatment Center to ensure security of all medications brought into the facility. When staff is made aware of a potential contraband issue, the Risk Manager, MHT/Counselor Aide Supervisor, and Clinical Supervisor will be made aware of the situation and will investigate the issue. The investigation may include interviews with patients, interviews with staff, and searches of patient rooms, belongings and persons. Documentation of the investigation will be completed by the person who is completing the interview or search. The Risk Manager will co-facilitate a training with the MHT/Counselor Aide Supervisor for all counselor aides to include search procedure, contraband and contraband searches (including proper disposition of contraband items found per policy), searches of patient belongings and procedure for daily room searches. The MHT/Counselor Aide Supervisor is responsible for monitoring all incidents of contraband that is brought into the facility and is required to report these findings monthly to the Performance Improvement Committee. Medications that are brought into the facility upon admission are given to nursing staff. Medications are inventoried by nursing staff and are then secured in a locked medication cart in the medication room at the nurses station. Re-education for all counselor aides will by completed prior to 11/5/11.
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709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on the review of client records and facility policy and procedure, the facility failed to discharge clients according to their policy and procedure.
The findings include:
A complaint investigation was conducted on September 27, 2011. On the evening of September 13, 2011 altercations between several residential patients took place. A fight broke out and a resident was injured as a result. A client who was assaulted during the incident was interviewed on September 27, 2011 and confirmed that the incident took place.
The facility's policy and procedure for Therapeutic Discharges states:
1.0 The patient will meet the criteria for Therapeutic Discharge when one of the following exits:
1.1 Non-compliance with treatment but not danger to self or others requiring court petition. Examples of behaviors include but are not limited to: inappropriate physical contact, physical fighting, verbal/terroristic threats, bringing drugs onto the unit, and not taking medications as directed.
Clients #6 and 10 were involved or had involvement with the altercation that occurred on September 13, 2011. The facility had limited documentation in client records about the altercation but during staff and client interviews on September 27, 2011 confirmed how each client played a role and in what capacity they played a role in the incidents that occurred on September 13, 2011.
Client #6 was admitted on September 13, 2011 and discharged on September 16, 2011.
Client #10 was admitted on September 9, 2011 and discharged on September 16, 2011.
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Plan of Correction
Criteria for involuntary discharge/termination is an individual-based clinical decision. A patient who is noncompliant with facility rules and policies will be given one verbal warning. If the patient continues to be noncompliant, he/she will be placed on a therapeutic contract. If the patient is noncompliant with the therapeutic contract, he/she will be therapeutically discharged. Each case is reviewed by the treatment team during pass-down meetings and recommendations are made based on the severity of the issue, the patient's motivation for treatment and the safety of the patient and the community. The clinical staff is responsible for notifying the DCS and/or Clinical Supervisor in all such situations and will oversee the therapeutic discharge process to ensure that it is followed appropriately. If it is necessary to therapeutically discharge a patient during non-business hours, the Administrator on Call will be contacted to assist in the process. The process for a safe discharge plan is initiated once it is determined that a therapeutic discharge is warranted. The DCS and/or Clinical Supervisor is responsible for revision of the current Therapeutic Discharge policy to include specific criteria for termination of treatment and to include the process for therapeutic discharge. The policy revision will be approved by the Medical Executive Committee prior to 11/18/11. The DCS and/or Clinical Supervisor will be responsible for auditing all charts of patient's who are therapeutically discharged to ensure that the process is followed according to facility policy. The results of the audit will be reported quarterly to the Performance Improvement Committee. The DCS and/or Clinical Supervisor will provide re-education to clinical staff on the therapeutic discharge process and documentation requirements prior to 11/25/11.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 and facility policy and procedure, the facility failed to document case consultations in four of twelve records reviewed.
The findings include:
Twelve client records was reviewed on September 27, 2011. Four of the twelve records were required to have documentation of case consultations as a result of the altercation that occurred at the facility on September 13, 2011, #5, 6, 10 and 11. Case consultations are to be conducted for several reasons:
1. To discuss a "problem" client who is not responding to the treatment strategy or has violated a project rule.
2. To discuss a client or a group of clients whose characteristics or response to treatment afford a unique opportunity for counselor training.
3. To assess client(s) who are due or need to progress to another phase of treatment.
4. To give each counselor an opportunity to present one or more cases for review and to obtain the benefits of a multi-disciplinary evaluation of some of his/her cases.
Clients #5, 6, 10 and 11 were involved in a altercation that occurred at the facility on September 13, 2011. The facility failed to document a case consultations for reason #1 due to each client breaking a project rule.
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Plan of Correction
It is the policy of Roxbury Treatment Center to maintain a complete client record on each individual that includes information relative to the client's involvement in treatment. Each patient shall have at least one case consultation note per treatment episode. In addition, case consultation notes will be completed given any changes to patient condition or response to treatment. The clinical staff will be required to meet once weekly to hold case conferences to ensure that each patient is discussed during case consultation prior to discharge. The DCS and/or Clinical Supervisor will provide re-education for clinical staff for case consultations to include the process for case consultations, communication of issues, responses to treatment, progression of treatment and documentation requirements prior to 11/5/11. The DCS and/or Clinical Supervisor will perform a random audit of 20 charts monthly to ensure that case consultations are completed and will report the findings monthly to the Performance Improvement Committee. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document discharge summaries in ten of twelve client records reviewed.
The findings include:
Twelve client records were reviewed on September 27, 2011 as a result of a complaint investigation. Ten of the twelve required to have a discharge summary documented in their records, #1, 2, 3, 4, 6, 7, 9, 10, 11 and 12. Discharge summaries are to be completed within 7 days after the client has been discharged and include these components: reason for treatment, services offered, response to treatment and client status at discharge.
Client # 1 was admitted on August 27, 2011 and discharged on September 14, 2011. Client #1's discharge summary was completed on September 18, 2011 and failed include the client response to treatment and clients status at discharge.
Client # 2 was admitted on September 6, 2011 and discharged on September 14, 2011. Client # 2's discharge summary was completed on September 20, 2011 and failed include the client response to treatment and clients status at discharge.
Client # 3 was admitted on September 7, 2011 and discharged on September 14, 2011. Client #3 's discharge summary was completed on September 20, 2011 and failed include the client response to treatment and clients status at discharge.
Client #4 was admitted on September 5, 2011 and discharged on September 16, 2011. Client # 4's discharge summary was documented in client record at the time of the complaint investigation. The discharge summary was to be completed by September 23, 2011.
Client #6 was admitted on September 13, 2011 and discharged on September 16, 2011. Client # 5's discharge summary was not documented in client record at the time of the complaint investigation. The discharge summary was to be completed by September 23, 2011.
Client #7 was admitted on September 1, 2011 and discharged on September 20, 2011. Client # 7's discharge summary was not documented in client record at the time of the complaint investigation. The discharge summary was to be completed by September 27, 2011.
Client #9 was admitted on August 23, 2011 and discharged on September 16, 2011. Client # 9 's discharge summary was not documented in client record at the time of the complaint investigation. The discharge summary was to be completed by September 23, 2011.
Client #10 was admitted on September 9, 2011 and discharged on September 16, 2011. Client 10 's discharge summary was completed on September 23, 2011 and failed to include the client response to treatment and clients status at discharge.
Client #11 was admitted on September 6, 2011 and discharged on September 19, 2011. Client's discharge summary was not documented in client record at the time of the complaint investigation. The discharge summary was to be completed by September 26, 2011.
Client #12 was admitted on September 8, 2011 and discharged on September 14, 2011. Client's discharge summary was completed on September 18, 2011 and failed to include the client response to treatment and clients status at discharge.
An interview with the performance improvement and staff development personnel on September 27, 2011 confirmed the findings.
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Plan of Correction
The DCS and/or Clinical Supervisor will provide re-education to clinical staff on discharge summary completion, required documentation and timeframes for completion. This training will include the review of the discharge summary process to include reason for treatment, services offered, response to treatment and client status at discharge. A random audit of 20 charts will be completed monthly by the DCS or designee to ensure compliance with documentation and timeframes and will be reported monthly to the Performance Improvement Committee.
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