INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2, 2020 through March 4, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.11(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.
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Observations
Based on an annual licensing renewal inspection conducted on March 2, 2020 through March 4, 2020, the project failed to ensure that employees #6 and #7 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a direct support professional on February 12, 2018 and was due to have the communicable disease trainings no later than February 12, 2020. 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 #7 was hired as a direct support professional on May 15, 2017 and was due to have the communicable disease trainings no later than May 15, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Prior to the end of the survey, both employees noted to be out of compliance were scheduled for the necessary trainings on 4/2/20 and 4/3/20. Since that time, both trainings were cancelled due to the COVID-19 virus. The Director of HR will continue to frequently check the department's Training Management System for updates and will schedule both employees for the earliest training once it is made available to ensure compliance with regulation 704.11. |
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 an annual licensing renewal inspection conducted on March 2, 2020 through March 4, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of fourteen client records reviewed.
Client #11 was admitted on August 27, 2019 and was discharged on September 1, 2019. A consent to release information form for the funding source was not documented in the client's record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On or before 3/30/20, all clinical staff were provided re-education by the Director of Clinical Services on ensuring that every patient record contains the appropriate release of information for the funding source. All intake staff were provided the same re-education by the Director of Admissions, who will provide oversight via random 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 an annual licensing renewal inspection conducted on March 2, 2020 through March 4, 2020, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 1 of 14 client records reviewed.
Client #4 was admitted on October 21, 2019 and was discharged on November 4, 2019. A consent to release form was signed and dated on October 21, 2019 to the client's employer that allowed for the release of the following: psychiatric discharge summary, psychosocial evaluation, educational information, psychiatric evaluation, consultations, labs and radiology data, concurrent review of treatment and family communication and insurance information.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Chart documentation indicates that the emergency contact that client #4 chose to provide was also the client's "boss." On or before 3/30/20, all clinical staff were provided re-education by the Director of Clinical Services on ensuring that every patient record contains the appropriate release of information for an employer and when feasible, a patient will be asked to provide an emergency contact that is not their employer. All intake staff were provided the same re-education by the Director of Admissions, who will provide oversight via random 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. |
709.33 (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 an annual licensing renewal inspection conducted on March 2, 2020 through March 4, 2020, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of two applicable client records reviewed.
Client #4 was admitted on October 21, 2019 and was administratively discharged on November 4, 2019. There was no documentation that the client received written notification of the project's decision to involuntarily terminate the client's treatment.
Client #5 was admitted on September 16, 2019 and was administratively discharged on October 16, 2019. There was no documentation that the client received written notification of the project's decision to involuntarily terminate the client's treatment.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On or before 3/30/20, all clinical staff were provided re-education by the Director of Clinical Services on ensuring that every patient who is administratively discharged is provided written notification of the decision to involuntarily terminate his/her treatment. A copy is to be provided to the patient and the original document is to be filed in the record. The Director of Clinical Services, or her designee, will provide oversight via chart audits of all administratively discharged patients. 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. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the census reports provided by the facility on March 2, 2020, the facility failed to maintain a daily census at or below the maximum census limitations outlined on the facility ' s license by the Department of Drug and Alcohol Programs (DDAP). The facility did not notify DDAP within 90 days requesting a change in the authorized maximum capacity of forty-six. At the time of the inspection, the census count was forty-eight.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to the end of the survey, the facility director provided a request to the department for 14 flex beds between both the inpatient non-hospital detoxification and inpatient non-hospital drug-free programs. On 3/5/20, the facility was granted this request, effective 3/2/20-3/1/21, and with the understanding that the facility may not exceed the number of beds permitted to be flexed per this exception in either activity or exceed the overall approved capacity for the facility at any time. The Director of Clinical Services or her designee will provide oversight to ensure compliance with regulation 709.14. |