INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22, 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 DPO on the requirements of fire drills. DPO will ensure monthly fire drills are conducted and conduct quarterly audits. Audit results will be reviewed quarterly in EOC committee. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of seven records reviewed.
Client #7 was admitted on September 18, 2023 and was still active at the time of the inspection. The record contained two informed and voluntary consents to an educational provider that were signed by the client on October 4, 2023, and November 29, 2023 that did not include the purpose of disclosure.
This is a repeat citation from the January 10, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Re-education was provided to the counselors on 1/22/2024. Counselors signed a re-education form and verbalized understanding of the proper way to fill out consents. Director of Outpatient, or designee, will conduct monthly chart audits to ensure compliance in this area. Corrections and re-educations will be made as needed. |
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 #2 was admitted on February 13, 2023 and was discharged on May 4, 2023. There was no documentation that a copy of an informed and voluntary consent to release information forms for a funding source, emergency contact, legal and medical providers dated February 13, 2023 were offered to the client.
Client #3 was admitted on February 23, 2023 and discharged on July 31, 2023. There was no documentation that a copy of an informed and voluntary consent to release information forms for a funding source, emergency contact and medical provider dated February 23, 2023 was offered to the client.
Client #6 was admitted on October 30, 2023 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a legal provider dated January 17, 2024 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 1/22/2024. 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 five out of five applicable records reviewed.
Client #2 was admitted on February 13, 2023 and was discharged on May 4, 2023. A treatment plan was completed on February 28, 2023, and the next update was due no later than April 28, 2023; however, there is no documentation that an update occurred.
Client #3 was admitted on February 23, 2023 and discharged on July 31, 2023. A treatment plan was completed on February 23, 2023, and the next update was due no later than April 23, 2023; however, it was not completed until June 7, 2023.
Client #4was admitted on September 27, 2023 and discharged on December 13, 2023. A treatment plan was completed on October 3, 2023, and the next update was due no later than December 3, 2023; however, there was no documentation that one was completed.
Client #6 was admitted on October 30, 2023 and was still active at the time of the inspection. A treatment plan was completed on October 31, 2023, and the next update was due no later than December 31, 2023; however, it was not completed until January 10, 2024.
Client #7 was admitted on September 18, 2023 and was still active at the time of the inspection. A treatment plan was completed on October 11, 2023, and the next update was due no later than December 11, 2023; however there is 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 1/22/2024 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. |