INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on December 4, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site 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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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to secure patient records. Patient records were observed on counters and in open, unlocked file cabinets.
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Plan of Correction
The chart cabinets were re-locked on 12/4/19 upon discovery that they were found to be open. Staff received re-education on or before 1/20/20 regarding confidentiality regulations, including the requirement that charts and associated documents should be secured at all times. The Director of Performance Improvement will provide weekly random observations to ensure compliance. Results will be reported in the weekly leadership team meeting and staff will be re-educated, as necessary, throughout the monitoring process. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to file a written unsual incident report with DDAP within 3 business days folllowing an incident requiring the presence of ambulance personnel at the facility.
A review of administrative documentation revealed that unusual incidents involving ambulance personnel at the facility were not reported to DDAP on the following dates in 2019: January 5, 22, and 27, March 7 and 23, April 28, May 26, June 6 and 23, July 1, 13, and 18, September 13, 16, 17, 18, and 19, October 17, November 3 and 5.
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Plan of Correction
The Director of Performance Improvement provided re-education to leadership team members on 1/8/20 regarding the requirements for reporting unusual incidents. The Director of Performance Improvement will provide oversight and audit 100% of all reported incidents to ensure that Unusual Incident Reports are properly completed and forwarded to the Department within the specified timeframe. Results will be reported in the weekly leadership team meeting and staff will be re-educated, as necessary, throughout the monitoring process. |