INITIAL COMMENTS
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General Comments:
This report is a result of an on-site licensure renewal inspection conducted on February 14 &15, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Roxbury Treatment Center, 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 and a plan of correction is due on March 21, 2008.
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Plan of Correction
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709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based upon a review of client records on February 15, 2008, the facility failed to provide aftercare plans that included goals with time frames in two of two client records reviewed, specifically client records # 6 & 7.
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Plan of Correction
The current Aftercare plan form has been reworded to prompt goals with specific time frames. Clinical staff were re-educated on March 14, 2008 regarding compliance with the requirement of aftercare goals to include specific time frames for completion.
The facility director will perform monthly audits in the form of random chart reviews to monitor compliance with standards and reinforce proper form protocol. Any identified deficiencies will be addressed through supervision and additional training as necessary.
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