INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24-25, 2021 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of nine personnel records, the facility failed to provide documentation of each counselor meeting at least one of the groups of qualifications for employee # 5.
Employee # 5 was hired as a counselor May 18, 2020 and is still in this position. After a review of the personnel record, it was determined the employee did not have at least three months of clinical experience or a practicum as required with a Master's degree.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately following the inspection, Employee #5 completed a new job description and her personnel file was amended to reflect the change in her position to Counselor Assistant. Since then, the Clinical Supervisor has been and will continue to provide the necessary supervision and oversight for this employee in accordance with the regulations pertaining to Counselor Assistants until she meets the department's experience requirements for the position of Counselor. Clinical leaders and Human Resources staff were provided re-education on the necessary education and work experience requirements for staff based upon the department's regulations. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed. An exit door from the women's detox unit was stuck and hard to open.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On the same date as the finding occurred, the Director of Plant Operations evaluated the exit door in question and found debris along the bottom of the doorframe. This was removed and the door was then found to be easily opened and the exit no longer obstructed. The Director of Plant Operations re-educated maintenance staff on ensuring that all doors are fully unobstructed when conducting environmental rounds. The Director of Plant Operations will provide ongoing oversight on proper completion of environmental rounds to ensure continued 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 three of fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client records # 12, 13, and 14.
Client # 12 was admitted on October 12, 2020 and was discharged on November 10, 2020. A letter to "To whom it may concern" was in the client record providing admission information and discharge information without an informed and voluntary consent from the client for the disclosure of information.
Client # 13 was admitted on October 26, 2020 and was discharged on December 10, 2020. Faxes sent to a medical group on December 11, 2020 provided continuing care, medication list, history and physical, and psychiatric evaluation without an informed and voluntary consent from the client for the disclosure of information.
Client # 14 was admitted on June 26, 2020 and was discharged on July 24, 2020. A letter to "To whom it may concern" was in the client record providing admission information and discharge information without an informed and voluntary consent from the client for the disclosure of information. Also, there was not an informed and voluntary consent from the client for the disclosure of information to the funding source.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 4, 2020 inspection.
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Plan of Correction
Clinical staff have been provided re-education by the 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. Client #13's information was disclosed to the medical group; however, the release of information was for the specific Primary Care Physician (PCP) who belonged to the stated medical group (address and other contact info was consistent). Nonetheless, intake staff have been provided re-education by the Director of Admissions on ensuring that all patients have valid releases of information for PCPs and funding sources. The Director of Admissions (or designee) 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 fourteen 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 to include the specific information disclosed.
Client # 12 was admitted on October 12, 2020 and was discharged on November 10, 2020. An informed and voluntary consent from the client for the disclosure of information to a funding agency dated October 12, 2020 allowed for the release of the psychiatric evaluation, discharge summary, continuing care plan, detox page, psychological evaluation, educational; information, psychiatric discharge summary, consultations, history and physical, lab/radiology data, concurrent review of treatment and family communication, demographic information, and insurance information.
Also, an informed and voluntary consent from the client for the disclosure of information dated November 30, 2020 to another drug and alcohol facility dated November 30, 2020, to a significant other dated November 9, 2020, and to an organization dated October 26, 2020 did not indicate the information to be released.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 4, 2020 inspection.
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Plan of Correction
Clinical staff have been provided re-education by the 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. Intake staff have been provided re-education by the Director of Admissions on ensuring that all patients have valid releases of information for funding sources. The Director of Admissions (or designee) 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. |
709.63(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 three of three applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual of occurring within a week for a referral or three months by mail for all other discharges.
Client # 5 was admitted on May 28, 2020 and was discharged on May 30, 2020. There was no documentation of follow-up information in the client record.
Client # 6 was admitted on June 30, 2020 and was discharged on July 5, 2020. There was no documentation of follow-up information in the client record.
Client # 7 was admitted on July 13, 2020 and was discharged on July 20, 2020. There was no documentation of follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
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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. |
709.52(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.
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Observations
Based on three of six applicable client records reviewed, the facility failed to document treatment and rehabilitation plans being reviewed at least every thirty days in client records # 9, 11, and 13.
Client # 9 was admitted on January 5, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 8, 2021. The next treatment plan update was due to occur no later than February 8, 2021 however, the next update did not occur until February 24, 2021.
Client # 11 was admitted on January 8, 2021 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on February 19, 2021. The next treatment plan update was due to occur no later than March 19, 2021.
Client # 13 was admitted on October 26, 2020 and was discharged on December 10, 2020. A treatment and rehabilitation plan was developed on November 3, 2020. The next treatment plan update was due to occur no later than December 3, 2020.
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 Director of Clinical Services on ensuring that all treatment plans, including updates, are fully completed and timely filed in the client record, per policy and regulation. The Director of Clinical Services or Clinical Supervisor will provide oversight via random weekly chart audits. Any issues with compliance of regulation 709.52(b) will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on six of seven client records reviewed, the facility failed to provide a complete client record to include an accurate record of services provided. The record of service is documented by a number system. Each number represents where the client is in the facility. Documentation of progress notes and record of service did not correspond accurately.
Client # 8 was admitted on February 14, 2021 and was still active at the time of the inspection. The record of service did not provide the same time frame for individual sessions as the progress notes.
Client # 9 was admitted on January 5, 2021 and was still active at the time of the inspection. The record of service did not provide the same time frame for individual sessions as the progress notes.
Client # 10 was admitted on December 29, 2020 and was still active at the time of the inspection. The record of service did not provide the same time frame for individual sessions as the progress notes.
Client # 11 was admitted on Jnauary 8, 2021 and was still active at the time of the inspection. The record of service did not provide the same time frame for individual sessions as the progress notes.
Client # 12 was admitted on October 10, 2020 and was discharged November 10, 2020. The record of service did not provide the same time frame for individual sessions as the progress notes.
Client # 13 was admitted on October 26, 2020 and was discharged December 10, 2020. The record of service did not provide the same time frame for individual sessions as the progress notes.
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 Director of Clinical Services on ensuring that all individual sessions are properly documented on the Record of Service form. 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)(3) will be reported in the weekly leadership team meeting and staff will be re-educated as necessary throughout the monitoring process. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on three of three applicable client records reviewed, the facility failed to provide documentation of case consultation notes in accordance with the facility policy and procedure. Per the facility manual, case consultations are to occur at least once during treatment.
Client # 12 was admitted on October 12, 2020 and was discharged on November 10, 2020. There was no documentation of a case consultation in the client record.
Client # 13 was admitted on October 26, 2020 and was discharged on December 10, 2020. There was no documentation of a case consultation in the client record.
Client # 14 was admitted on June 26, 2020 and was discharged on July 24, 2020. There was no documentation of a case consultation in the client record.
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 Director of Clinical Services on ensuring that all client records contain one or more properly completed case consultation notes. 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)(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)(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 three of three applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual of occurring within a week for a referral or three months by mail for all other discharges.
Client # 12 was admitted on October 12, 2020 and was discharged on November 10, 2020. There was no documentation of follow-up information in the client record.
Client # 13 was admitted on October 26, 2020 and was discharged on December 10, 2020. There was no documentation of follow-up information in the client record.
Client # 14 was admitted on June 26, 2020 and was discharged on July 24, 2020. There was no documentation of follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
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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. |