INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 19, 2022 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a written semiannual performance evaluation based upon measurable performance standards during the first 6 months in a counselor assistant position.
Employee # 8 was hired as a counselor assistant on March 14, 2021 and was still in this position at the time of the inspection. A semi-annual performance evaluation was due to occur no later than September 14, 2021. The performance evaluation provided by the facility occurred on December 23, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #8 is no longer employed with the facility. At the time of the survey, the Clinical Supervisor was provided re-education by the Director of PI on ensuring proper supervision and accompanying documentation of all counselor assistants, which includes the written semiannual performance evaluation based upon measurable performance standards during the first 6 months of hire in the counselor assistant position. The Clinical Supervisor or Director of Clinical Services will maintain an ongoing 100% audit of all counselor assistants to ensure compliance with 704.9(b). |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of employee records, the facility failed to provide documentation of direct observation occurring during close supervision of the employee in personnel records # 6, 7, and 8.
Employee # 6 was hired as a counselor assistant on November 8, 2021 and was still in this position at the time of the inspection.
Employee # 7 was hired as a counselor assistant on January 13, 2021 and was still in this position at the time of the inspection.
Employee # 8 was hired as a counselor assistant on March 14, 2021 and was still in this position at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the survey, the Clinical Supervisor was provided re-education by the Director of PI on ensuring proper supervision and accompanying documentation of all counselor assistants, which includes evidence and evaluation of direct observations. The Clinical Supervisor or Director of Clinical Services will maintain an ongoing 100% audit of all counselor assistants to ensure compliance with 704.9(c). |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Cameras are located in group rooms and a counselor office and allow therapy sessions to be recorded.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of the survey, the Director of PI re-educated the necessary leadership team members on ensuring compliance with 705.4(3). Counseling sessions will only be held in camera-free spaces. Counselors will ensure that counseling sessions are not recorded or conducted within camera view. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to keep all clean cooking utensils stored in a clean enclosed area. Cooking utensils were hanging from hooks from the ceiling.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Plant Operations (DPO) and Dietary Manager re-educated dietary staff on 1/26/22 on proper storage of clean cooking utensils. The DPO or Dietary Manager will complete random ongoing weekly audits to ensure compliance with 705.7(b)(3). Re-education with dietary staff will occur, as necessary to ensure ongoing compliance. |
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.
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Observations
Based on two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 4 and # 10.
Client # 4 was admitted on December 17, 2021 and was still active at the time of the inspection. A letter allowing admit and discharge information dated December 20, 2021 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information.
Client # 10 was admitted on August 23, 2021 and was discharged on October 5, 2021. A letter allowing admit and discharge information dated October 5, 2021 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 25, 2021 and March 4, 2020 annual licensing inspection.
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Plan of Correction
Clinical staff have been provided re-education by the Clinical Supervisor/Director of Clinical Services on ensuring that all treatment verification letters are specifically addressed to the appropriate party with a valid corresponding release of information, or addressed to the patient themselves. The Director of Clinical Services or Clinical Supervisor will provide oversight via random weekly chart audits. Any issues with compliance of regulation 709.28 will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 4 was admitted on December 17, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 27, 2021 to an emergency contact and dated January 12, 2022 to a county agency did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 25, 2021 and March 4, 2020 annual licensing inspection.
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Plan of Correction
The current client releases were corrected at the time of the inspection. Clinical staff have been provided re-education by the Clinical Supervisor/Director of Clinical Services on ensuring that all releases of information are appropriately and fully completed. The Director of Clinical Services or Clinical Supervisor will provide oversight via random weekly chart audits. Any issues with compliance of regulation 709.28 will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 4 was admitted on December 17, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 20, 2021 to health agency did not provide the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current client releases were corrected at the time of the inspection. Clinical staff have been provided re-education by the Clinical Supervisor/Director of Clinical Services on ensuring that all releases of information are appropriately and fully completed. The Director of Clinical Services or Clinical Supervisor will provide oversight via random weekly chart audits. Any issues with compliance of regulation 709.28 will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on four of ten applicable client records reviewed, the facility failed to provide documentation of the administration of medication according to the facility policy and procedure manual. The policy and procedure manual indicates that both the staff will initial the medication administration record for documenting medication.
Client # 2 was admitted on October 29, 2021 and was still active at the time of the inspection. A medication prescribed to be taken one time in the am was not documented on the medication administration record by initial to have been taken one time in the am on the dates of November 2, 9, 14, 17, 18, and 30. A medication prescribed to be taken at 1700 was not documented on the medication administration record by to have been taken at 1700 on the dates of November 1-14, 17, 18, 22, 23, 26-28, and 30.
Client # 3 was admitted on December 22, 2021 and was still active at the time of the inspection. A medication prescribed to be four times daily was not documented on the medication administration record by initial to have been taken four times daily on the dates of December 23 and 29.
Client # 4 was admitted on December 17, 2021 and was still active at the time of the inspection. Three medications prescribed to be taken one time in the am was not documented on the medication administration record by initial to have been taken one time in the am on the dates of November 11, 12, and December 31. A medication prescribed to be taken at 2:00 was not documented on the medication administration record by initial to have been taken at 2:00 on the dates of December 31.
Client # 5 was admitted on November 18, 2021 and was still active at the time of the inspection. Several medications prescribed to be taken one time in the am was not documented on the medication administration record by initial to have been taken one time in the am November 20, 24, 25, 26, 28, December 5, 7, 12, 13, 14, 11, 12, 16, 30 and January 13, 17, and 18. A medication prescribed to be taken two times daily was not documented on the medication administration record by initial to have been taken at two times daily on the dates of November 28, December 16, 30, and January 13, 17, 18, and 19.December 31.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Nursing (DON) provided re-education to all nursing staff on ensuring proper documentation of medication administration. The DON (or designee) will provide oversight via random weekly chart audits. Any issues with compliance of regulation 790.32 will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on two of two applicable client records reviewed, the facility failed to notify the client in writing of a decision to involuntarily terminate the client's treatment in client records # 7 and 8.
Client # 7 was admitted on August 18, 2021 and was therapeutically discharged on August 19, 2021.
Client # 8 was admitted on August 27, 2021 and was therapeutically discharged on September 6, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff have been provided re-education by the Clinical Supervisor/Director of Clinical Services on ensuring that every patient who is administratively discharged receives written notification of the decision to involuntarily terminate their treatment. The Director of Clinical Services or Clinical Supervisor will provide oversight via 100% chart audits of all patients who are involuntarily terminated from treatment. Any issues with compliance of regulation 709.33 will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on three of three applicable detox client records reviewed, the facility failed to provide a complete client record to include a discharge summary in accordance with the facility policy and procedure manual for a discharge plan to be completed within thirty days of discharge in client records # 6, 7, and 8.
Client # 6 was admitted on June 19, 2021 and discharged on June 21, 2021. The discharge summary in the client record was not completed until December 16, 2021.
Client # 7 was admitted on August 18, 2021 and discharged on August 19, 2021. The discharge summary in the client record was not completed until January 19, 2022.
Client # 8 was admitted on August 27, 2021 and discharged on September 6, 2021. The discharge summary in the client record was not completed until January 19, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff have been provided re-education by the Clinical Supervisor/Director of Clinical Services on ensuring that all discharge summaries are completed timely and per policy. The Director of Clinical Services or Clinical Supervisor will provide oversight via random weekly chart audits. Any issues with compliance of regulation 709.63(a)(7) will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on two of three applicable detox client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up occurring within a week for a referral or three months by mail for all other discharges.
Client # 7 was admitted on August 18, 2021 and discharged on August 19, 2021. There was no follow-up information documented in the client record.
Client # 8 was admitted on August 27, 2021 and discharged on September 6, 2021. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 25, 2021 annual licensing inspection.
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Plan of Correction
The Director of Clinical Services has provided re-education to the Clinical Supervisor on ensuring that aftercare follow up is fully completed in the appropriate timeframe and documented in the client record. The Director of Clinical Services (or designee) will provide oversight via random weekly chart audits. Any issues with compliance of regulation 709.63(a)(8) will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |
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 two of two applicable residential client records reviewed, the facility failed to provide a complete client record to include a discharge summary in accordance with the facility policy and procedure manual for a discharge plan to be completed within thirty days of discharge in client records # 9 and 10.
Client # 9 was admitted on August 2, 2021 and discharged on August 17, 2021. The discharge summary in the client record was not completed until January 19, 2022.
Client # 10 was admitted on August 23, 2021 and discharged on October 5, 2021. The discharge summary in the client record was not completed until November 10, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff have been provided re-education by the Clinical Supervisor/Director of Clinical Services on ensuring that all discharge summaries are fully completed, timely, and per policy. The Director of Clinical Services or Clinical Supervisor will provide oversight via random weekly chart audits. Any issues with compliance of regulation 709.53(a)(10) will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on one of two applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up occurring within a week for a referral or three months by mail for all other discharges.
Client # 10 was admitted on August 23, 2021 and discharged on October 5, 2021. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 25, 2021 annual licensing inspection.
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Plan of Correction
The Director of Clinical Services has provided re-education to the Clinical Supervisor on ensuring that aftercare follow up is fully completed in the appropriate timeframe and documented in the client record. The Director of Clinical Services (or designee) will provide oversight via random weekly chart audits. Any issues with compliance of regulation 709.53(a)(11) will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |