INITIAL COMMENTS
|
This report is the result of an on-site licensure renewal inspection conducted on February 6 to 9, 2012, by staff from the Division of Drug and Alcohol 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:
|
Plan of Correction
|
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.
|
Observations
Based on the physical plant inspection, the facility failed to store eating utensils and plates in a clean enclosed area..
The findings include:
The physical plant inspection was conducted on February 8, 2012. At approximately 9:30 a.m.., eating utensils were observed being stored in open containers in the cafeteria.
The Director of Plant Operations confirmed the findings.
|
Plan of Correction
The Dietary Manager has provided re-education on requirements of storing eating utensils and plates to dietary staff. A procedure for storing eating utensils and plates in a clean enclosed area was implemented. Education and procedure implementation was completed by February 13, 2012.
The Dietary Manager will ensure compliance by monitoring storage areas on a daily basis. In addition, monthly monitoring will be completed by members of the EOC committee. |
705.7 (b) (4) 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:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
|
Observations
Based on the physical plant inspection, the facility failed to ensure that storage areas for foods were free of food particles, dust and dirt.
The findings include:
The physical plant inspection was conducted on February 8, 2012. At approximately 9:30 a.m. noticeable spills and food particles were observed on the floor of the walk-in freezer.
The Director of Plant Operations confirmed the findings.
|
Plan of Correction
The Dietary Manager has provided re-education to dietary staff on proper cleaning of food storage areas. Re-education was completed by February 13, 2012. Daily cleaning procedures will be followed per facility policy and will be monitored by the Dietary Manager. In addition, monthly monitoring will be completed by members of the EOC Committee. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on February 7, 2012. No letter of agreement regarding 24-hour emergency medical coverage was documented.
The Facility Director, CEO and multiple staff members were presented the findings. The findings were not disputed.
|
Plan of Correction
The Risk Manager has obtained a letter of agreement with Waynesboro Hospital for 24-hour emergency medical coverage for the facility. This was completed by February 27, 2012.
The Risk Manager will perform annual reviews of referral agreements and will report findings annually to the Medical Executive Committee. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
|
Observations
Based on a physical plant inspection, the facility failed to secure patient records in locked storage containers.
The findings include:
The physical plant inspection was conducted on February 8, 2012, between approximately 9:30 AM and 11:00 AM. At the time of inspection, active client records were stored on open shelves in the nursing station.
The Director of Plant Operations, Facility Director, CEO and multiple staff members were presented the findings. The findings were not disputed.
|
Plan of Correction
The Director of Plant Operations will facilitate providing locked storage areas where patient records will be secured on each unit. Projected date for completion is March 31, 2012.
Compliance with storage of patient records will be monitored monthly by members of the EOC Committee and the PI Director. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on the review of client records, the facility failed to document the specific information disclosed on consent to release information forms in two out of five records.
The findings include:
From February 8-9, 2012, consent to release information forms were reviewed in five client records, specifically records # 1, 2, 3, 4 and 5. The facility did not document the specific information that was disclosed on the consent to release information forms in client records # 2 and 5.
Client # 2 was admitted on 1/30/12. A fax cover sheet in client # 2's record stated his Biopsychosocial Evaluation, Medication List, Psychiatric Evaluation, Medical History and Physical Exam were released to a social service agency. The consent to release information form for the social service agency did not state that these items would be released.
Client # 5 was admitted on 10/14/11. A fax cover sheet in client # 5 ' s record stated his Biopsychosocial Evaluation, Medication List, Psychiatric Evaluation, Medical History and Physical Exam were released to a social service agency. The consent to release information form for the social service agency did not state that these items would be released.
The Project director and Facility Director were presented the findings. The findings were not disputed.
|
Plan of Correction
The Director of PI has revised the facilities consent to release information form to include specific information to be disclosed. This revision was approved by Medical Executive Committee on February 29, 2012. All clinical/nursing staff will be educated on the new release form and requirements for completion by March 16, 2012.
The Director of Admissions will monitor consent forms for proper completion and will report findings monthly to PI Committee. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
|
Observations
Based on a review of facility policy, a review of the client handbook, and a physical plant inspection, the facility failed to inform clients of their rights.
The findings include:
The facility's policy was reviewed on February 6, 2012. The facility's policy stated that clients would be informed of their rights via the Patient Bill of Rights, and and information that pertained to these rights would be displayed in the waiting room, lobby area and other areas frequented by persons receiving services.
On February 8, 2012, the Patient Bill of Rights was reviewed. The Patient Bill of Rights did not inform the clients of the right to appeal a decision limiting access to their record.
On February 8, 2012 at approximately 9:30 a.m., during the physical plant inspection, a review of the posted information was completed. The facility did not display the patient rights in any public areas designated in their policy.
On February 8, 2012, the client handbook was reviewed. The client handbook did not inform the clients of the right to appeal a decision limiting access to their record.
The Director of Plant Operations, Facility Director, CEO and multiple staff members were presented the findings. The findings were not disputed.
|
Plan of Correction
In addition to displaying the patient's Bill of Rights in the admissions department and all units, it will be displayed in the main lobby of the facility. This will be completed by the Director of Plant Operations completed by March 16, 2012. Compliance will be monitored by monthly by members of the EOC committee and the Director of PI.
The Risk Manager will revise the patient handbooks to include the client's right to appeal a decision limiting access to their record. Projected date for completion will be March 16, 2012.
The Risk Manager will review Patient Handbooks annually and will update Handbooks as needed when changes are required. |
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.
|
Observations
Based on the review of client records, the facility failed to document a case consultation in three out of six records.
During the on-site survey inspection February 8 and 9, 2012, six client records requiring case consultations were reviewed, specifically records # 1, 2, 3, 5, 8 and 9. The facility did not document at least one case consultation during treatment, as per the project's policy, in client records # 5, 8 and 9.
Client # 5 was admitted on 10/14/11 and discharged on 10/29/11. Client # 5's record did not contain a case consultation.
Client # 8 was admitted on 10/8/11 and discharged on 11/19/11. Client # 8's record did not contain a case consultation.
Client # 9 was admitted on 1/4/12 and discharged on 1/15/12. Client # 9's record did not contain a case consultation.
The Facility Director was presented the findings. The findings were not disputed.
|
Plan of Correction
The Clinical Supervisor will provide re-education to all clinical staff on requirements for completion of case consultation notes by March 16, 2012. The Clinical Supervisor will complete chart audits to monitor compliance and report to the PI Committee monthly. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
|
Observations
Based on the physical plant inspection, the facility failed to display the hours of operation to the public.
The findings include:
The physical plant inspection was conducted on February 8, 2012. At approximately 9:30 a.m., a review was completed and the positing regarding the facility's hours of operation could not be located.
The Director of Plant Operations confirmed the that the facility did have the facility's hours of operation posted during the inspection..
|
Plan of Correction
The facility will display hours of operation in the main lobby and the admissions department. This will be completed by the Director of Plant Operations by March 16, 2012.
Compliance with this standard will be monitored by members of the EOC committee and the PI Director during monthly facility inspection. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
|
Observations
Based on the physical plant inspection, the facility failed to display the emergency phone number to the public.
The findings include:
The physical plant inspection was conducted on February 8, 2012. At approximately 9:30 a.m., a review a physical plant failed to provide confirmation that the facility displayed the emergency contact number.
The Director of Plant Operations confirmed that the facility's emergency contact number had not been publicly displayed
|
Plan of Correction
The facility will display an emergency phone number to the public in the main lobby and in the admissions department of the hospital. The Director of Plant Operations will complete this by March 16, 2012.
Compliance with this standard will be monitored by members of the EOC committee and the PI Director monthly during facility inspection. |