INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 23, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of ten personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that two 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 #9 was hired as a counselor aide on February 15, 2021 and was still employed in that position at the time of the inspection. Employee #9 was due to have the communicable disease trainings no later than February 15, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #10 was hired as an intake coordinator on August 31, 2021 and was still employed in that position at the time of the inspection. Employee #10 was due to have the communicable disease trainings no later than August 31, 2023. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
This is a repeat citation from the January 12, 2023 licensing process.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Re-education was provided to Director of Human Resources on 1/31/2024 on the training requirements for TB/STD training. Employee number 9 and 10 will be scheduled for the TB/STD training and will immediately forward their certificates to both their direct supervisor and the Director of Human Resources to ensure follow up and completion. The Director of Human Resources will monitor the required training dates and maintain communication with staff and their direct supervisors to maintain compliance. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that the inpatient nonhospital treatment and rehabilitation activity serving adult clients have one FTE counselor for every eight clients.
The facility FTE is determined by dividing the total number of hours devoted to the current number of clients by the facility's workweek. Then to obtain the facility ' s ratio, the total number of clients is divided by the FTE.
The facility was reported to have 175 hours per week devoted to their 46 clients.
The facility FTE caseload calculation is as follows: 175/40=3.37 (FTE); 46/3.37= 13.64, which equals to a client/counselor ration of 13/1.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Employee number 4 is the discharge coordinator, devoted to 40 hours a week of direct client care. With those hours added the caseload calculation is 215/40=5.37 (FTE); 45/5.37=8.5, which equals 8/1 client/counselor ratio. Performance Improvement Director is responsible for completing the Staffing Summary Sheets and was provided a re-education of including the discharge coordinator. Re-education was completed on 1/31/2024. The Clinical Coordinator in conjuncture with the Director of Intake, is responsible for monitoring the staff to client ratio. Clinical coordinator informs Intake of how many staff are working, so intake knows how many new clients can be admitted. |
709.28 (c) 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.
|
Observations
Based on a review of client records and discussion with facility staff, the facility failed to obtain an informed and voluntary consent to release information form prior to releasing information in four out of eleven records reviewed.
Client #6 was admitted on April 5, 2023 and discharged on May 18, 2023. The record contained documentation that information was disclosed to a drug and alcohol provider; however, there was no documentation of a signed informed and voluntary consent to release information from the client.
Client #9 was admitted on April 17, 2023 and discharged on May 30, 2023. The record contained documentation that information was disclosed to a pharmacy and a drug and alcohol provider; however, there was no documentation of a signed informed and voluntary consent to release information from the client for either.
Client #10 was admitted on May 6, 2023 and discharged on June 30, 2023. The record contained documentation that information was disclosed to a medical provider, a pharmacy and a drug and alcohol provider; however, there was no documentation of a signed informed and voluntary consent to release information from the client.
Client #11 was admitted on April 26, 2023 and discharged on June 2, 2023. The record contained documentation that information was disclosed to a pharmacy and a drug and alcohol provider; however, there was no documentation of a signed informed and voluntary consent to release information from the client.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Re-education was provided to the discharge coordinator on 1/23/2024 on when consents are required and why. Re-education was provided to all the counselors on 2/7/2024 regarding consent completion. Clinical supervisor will complete weekly chart reviews to ensure consents are being completed per policy. Data will be reported to Performance Improvement Committee monthly. Staff educator will educate nursing on the correct way to fill out consents for the pharmacy if medications are being called into the pharmacy. Re-education will take place by 3/8/2024. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
|
Observations
Based on a review of client records and the facility ' s policy and procedure manual, the facility failed to follow the facility ' s methods for control and accountability of drugs in two out of eleven client records.
Client # 6 was admitted on April 5, 2023 and discharged on May 18, 2023. The client was prescribed four different medications and the prescriptions stated that one tablet was to be taken in the evening. The medication administration records showed that the medications were not given in the evening on May 2 and 6, 2023. There was no documentation completed per the facility policy that included a reason why the medications were not given as prescribed.
Client # 10 was admitted on May 6, 2023 and discharged on June 30, 2023.
The client was prescribed three medications and the prescriptions stated that one tablet was to be taken in the evening. The medication administration records showed that the medications were not given on the evening of June 4, 2023. There was no documentation completed per the facility policy that included a reason why the medications were not given as prescribed.
This is a repeat citation from the January 19, 2022 and January 12, 2023 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The nurse manager re-educated nursing staff on the Medication Administration Policy. Re-education was provided to all nurses by 1/31/2024. Medication errors are reported monthly in the Performance Improvement Committee. Roxbury now has electronic MAR's, and this assists the nursing staff in documenting per policy. When documenting is missed, the screen will turn red and this assists nursing in fixing the missed documentation immediately. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of six applicable records reviewed.
Client #4 was admitted on November 15, 2023 and was still active at the time of the inspection. A treatment plan was completed on November 6, 2023, and the next update was due no later than November 21, 2023; however, there is no documentation that one was completed.
Client #6 was admitted on April 5, 2023 and discharged on May 18, 2023. A treatment plan was completed on April 10, 2023, and the next update was due no later than April 24, 2023; however, there is no documentation that one was completed.
Client #10 was admitted on May 6, 2023 and discharged on June 30, 2023. A treatment plan was completed on May 10, 2023 and the next update was due no later than May 24, 2023; however, there was no documentation that one was completed.
Client #11 was admitted on April 26, 2023 and discharged on June 2, 2023. A treatment plan was completed on May 1, 2023 and the next update was due no later than May 15, 2023; however, there was no documentation that one was completed.
This is a repeat citation from the January 12, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Re-education was given to all counselors on 2/7/2024. The clinical supervisor, or her designee, will complete weekly chart audits to ensure that all treatment plan updates are completed per policy and in the required time frame. Re-education will be completed as needed throughout the audit process. Any missed reviews will be corrected immediately. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for Medication Control was submitted and approved by the Department for the January 19, 2022 and January 12, 2023 annual licensing inspection. Medication Control was again found to be a deficiency in the January 23, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of corrections will be monitored by the Performance Improvement Committee and reported on monthly. The Performance Improvement Director will be responsible for monitoring the plan of corrections and working with the department leads to ensure audits and re-educations are occurring. Next Performance Improvement committee is 2/27/2024. |