INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 12-13, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Roxbury was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.3(c) LICENSURE Clerical/Support Staff
704.3. General requirements for projects.
(c) Clerical and other support staff shall be employed in sufficient numbers to insure efficient and safe operation of all of the services provided by the project.
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Observations
Based on a review of employee timesheets from February 8, 2026, through February 17, 2026, along with the daily detoxification and inpatient patient census, the facility failed to have a sufficient number of support staff to ensure efficient and safe operation of all the services provided.
On February 8, 2026, the facility had a census of 0 detoxification patients and 39 inpatient clients. From 12 am - 1 am there were 2 support staff working. From 1am- 1:30 am there was 1 support staff working. From 1:30 am - 6:16 am there were 2 support staff working. From 1:21 pm - 3:58 pm there were 2 support staff working. From 7:33 pm - 12 am there were 2 support staff working.
On February 9, 2026, the facility had a census of 0 detoxification patients and 37 inpatient clients. From 12 am - 1:57 am there were 2 support staff working. From 7:03 pm - 10:33 pm there was 1 support staff working. From 10:33 pm - 12 am there were 2 support staff working.
On February 10, 2026, the facility had a census of 0 detoxification patients and 39 inpatient clients. From 12 am - 6:31 am there were 2 support staff working. From 7:05 pm - 10:21 pm there was 1 support staff working. From 10:21 pm - 12 am there were 2 support staff working.
On February 11, 2026, the facility had a census of 0 detoxification patients and 39 inpatient clients. From 12 am - 1:57 am there were 2 support staff working. From 9:37 pm - 10:30 pm there were 2 support staff working. From 11:14 pm - 12 am there were 2 support staff working.
On February 12, 2026, the facility had a census of 0 detoxification patients and 41 inpatient clients. From 12 am - 1:59 am there were 2 support staff working. From 9:16 pm - 10:31 pm there were 2 support staff working.
On February 13, 2026, the facility had a census of 0 detoxification patients and 41 inpatient clients. From 7:01 pm - 12 am there were 2 support staff working.
On February 14, 2026, the facility had a census of 0 detoxification patients and 41 inpatient clients. From 12 am - 12:06 am there were 2 support staff working. From 12:06 am - 7:44 am there was 1 support staff working. From 7:44 am - 6:45 pm there was 0 support staff working. From 6:45 pm - 12 am there was 1 support staff working.
On February 15, 2026, the facility had a census of 0 detoxification patients and 40 inpatient clients. From 12 am - 10:35 am there was1 support staff working. From 10:35 am - 6:19 pm there was 0 support staff working. From 6:19 pm - 7:06 pm there was 1 support staff working. From 7:06 pm - 11:35 pm there were 2 support staff working. From 11:35 pm - 12 am there was 1 support staff working.
On February 16, 2026, the facility had a census of 1 detoxification patient and 42 inpatient clients. From 12 am - 6:19 pm there were 2 support staff working. From 9:19 pm - 10:44 pm there were 2 support staff working. From 11:18 pm - 12 am there were 2 support staff working.
On February 17, 2026, the facility had a census of 0 detoxification patients and 44 inpatient clients. From 12 am - 1:53 am there were 2 support staff working. From 9:44 pm - 10:29 pm there were 2 support staff working.
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Plan of Correction
ACTIONS:
1. The Director of Performance Improvement and Director of Nursing reviewed the facility policy on Patient Care Assignment sheets and revised the policy to include clear direction on updating the assignment sheet with any staff change.
2. All Nursing staff under the DDAP licensed program with responsibilities for completing the patient care assignment sheet were provided with re-education on proper completion of the assignment sheet, including updates with staff changes to reflect unit staffing at any given time. Training is documented by signed attestation.
3. The Director of Nursing or designee will maintain staffing assignment sheets for each shift to ensure adequate support staff coverage is available to support the safe and efficient operation of all services. Nursing leadership will review staffing patterns and make adjustments as necessary to maintain appropriate coverage.
MONITORING:
1. The Director of Nursing or designee will review staffing assignment sheets weekly to verify adequate clerical and support staff coverage is maintained for each shift
2. Daily, staffing needs and actions are discussed with the facility leadership team in operations meeting and through the weekend in conjunction with the Administrator on Call.
Staffing trends and completion compliance of assignment sheets to reflect staffing will be reported through the facility's Performance Improvement program for a period of six months.
RESPONSIBLE: Director of Nursing
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704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
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Observations
Based on a review of employee timesheets from February 8, 2026, through February 17, 2026, along with the daily detoxification and inpatient patient census, the facility failed to have awake staff coverage 24 hours a day.
On February 14, 2026, the facility had a census of 0 detoxification patients and 41 inpatient clients. Documentation shows no staff were working from 7:44 am - 9:08 am and from 3:39 pm - 4:24 pm.
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Plan of Correction
ACTIONS:
1. The Director of Performance Improvement and Director of Nursing reviewed the facility policy on Patient Care Assignment sheets and revised to policy to include clear direction on updating the assignment sheet with any staff change.
2. All Nursing staff under the DDAP licensed program with responsibilities for completing the patient care assignment sheet were provided with re-education on proper completion of the assignment sheet, including updates with staff changes to reflect unit staffing at any given time. Training is documented by signed attestation.
3. The Director of Nursing or designee will maintain staffing assignment sheets for each shift to ensure adequate support staff coverage is available to support the safe and efficient operation of all services. Nursing leadership will review staffing patterns and make adjustments as necessary to maintain appropriate coverage.
4. The Director of Human Resources has completed a review of the facility's staffing plan and implemented revisions to ensure awake staff coverage is maintained on all shifts. Staffing patterns will be continuously evaluated and adjusted as needed to support client safety, regulatory compliance, and the effective delivery of services.
MONITORING:
1. The Director of Nursing or designee will review staffing assignment sheets weekly to verify adequate clerical and support staff coverage is maintained for each shift
2. Daily, staffing needs and actions are discussed with the facility leadership team in operations meeting and through the weekend in conjunction with the Administrator on Call.
Staffing trends and completion compliance of assignment sheets to reflect staffing will be reported through the facility's Performance Improvement program for a period of six months.
RESPONSIBLE: Director of Nursing
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of the facility's Patient Rights, the facility failed to follow its Patient Rights.
Per the Patient Rights, patients have the right to be treated with dignity and respect, to receive care in a safe setting, to be free from all forms of abuse or harassment.
Patient # 2 was admitted on February 9, 2026, and discharged on February 11, 2026. The patient arrived for admission at 2:45 pm and remained in the intake lobby until 6:30 pm. During that time the patient was the victim of an unprovoked physical assault by another patient who was onsite for services other than substance use disorder.
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Plan of Correction
ACTIONS:
1. The Director of Admissions reviewed the circumstances surrounding Patient #2's admission and identified that the patient remained in the intake lobby for an extended period while awaiting admission resulting in inadequate protection of the patient's right to receive care in a safe setting free from abuse or harassment.
2. The Director of Admissions revised the admission process to ensure that individuals waiting admission are continuously monitored and placed in a safe and supervised environment while admission activities are being completed.
3. Admissions staff and nursing personnel were re-educated regarding their responsibility to promptly communicate delays in admission and to implement appropriate supervision and safety measures for patients awaiting admission.
4. Leadership reviewed staffing and operational procedures to ensure that patients are not left in the intake lobby for prolonged periods without ongoing observation and intervention as needed.
MONITORING:
1. The Director of Admissions or designee will conduct monthly audits of 10 admission records to monitor the length of time between arrival and admission and to ensure that appropriate supervision and safety measures were provided while patients awaited admission.
2. Any instances involving extended wait times or concerns regarding patient safety during the admission process will be reviewed weekly during our leadership meeting. This will take place for a period of six months.
RESPONSIBLE: Director of Admissions
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of the facility's Patient Rights, the facility failed to include in its Patient Rights that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Plan of Correction
ACTIONS:
1.The Director of Admissions reviewed and revised The Patient Rights document to include language informing individuals that they retain all civil rights and liberties except as otherwise provided by statute and that no client may be deprived of a civil right solely by reason of treatment.
2.The Staff Educator in conjunction with the Director of Admissions re-educated the admissions staff on the Patient Rights document and requirements related to notification of patient rights.
MONITORING: The Director of Admissions or designee will conduct monthly audits of 10 admission records to verify that the Patient Rights document contains all required civil rights language is provided to patients upon admission and that signed acknowledgment is maintained in the record. Audit findings will be reported monthly through Performance Improvement Committee for a period of six months.
RESPONSIBLE: Director of Admissions
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's Patient Rights, the facility failed to include in its Patient Rights that the project may not discriminate in the provision of services on the basis of ethnicity, marital status, and handicap.
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Plan of Correction
ACTIONS:
1.The Director of Admissions reviewed and revised the Patient Rights document to include language informing individuals that they may not be discriminated against in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion.
2.The Staff Educator in conjunction with the Director of Admissions re-educated the admissions staff on the Patient Rights document and the requirements related to notification of patient rights.
MONITORING: The Director of Admissions or designee will conduct monthly audits of 10 admission records to verify that the Patient Rights document contains all required regulatory language and is provided to patients upon admission and signed acknowledgement is maintained in the record. Audit findings will be reported monthly through Performance Improvement Committee for a period of six months.
RESPONSIBLE: Director of Admissions
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of the facility's Patient Rights, the facility failed to include in its Patient Rights that clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Plan of Correction
ACTIONS:
1.The Director of Admissions reviewed and revised The Patient Rights document to include language informing individuals of their right to inspect their own records in accordance with applicable laws and regulations.
2.The Staff Educator in conjunction with the Director of Admissions re-educated the admissions staff on the Patient Rights requirements and implementation process.
MONITORING: The Director of Admissions or designee will conduct monthly audits of 10 admission records to verify that the Patient Rights document contains all required regulatory language and is provided to patients upon admission and that signed acknowledgment is maintained in the record. Audit findings will be reported monthly through Performance Improvement Committee for a period of six months.
RESPONSIBLE: Director of Admissions
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of the facility's Patient Rights, the facility failed to include in its Patient Rights that clients have the right to appeal a decision limiting access to their records to the director.
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Plan of Correction
ACTIONS:
1.The Director of Admissions reviewed and revised The Patient Rights document to include language informing individuals of their right to appeal a decision limiting access to their records to the facility director.
2.The Staff Educator in conjunction with the Director of Admissions re-educated the admissions staff on the Patient Rights requirements and the process for addressing record access requests and appeals.
MONITORING: The Director of Admissions or designee will conduct monthly audits of 10 admission records to verify that the Patient Rights document contains all required regulatory language and is provided to patients upon admission and that signed acknowledgment is maintained in the record. Audit findings will be reported monthly through Performance Improvement Committee for a period of six months.
RESPONSIBLE: Director of Admissions
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of the facility's Patient Rights, the facility failed to include in its Patient Rights that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Plan of Correction
ACTIONS:
1.The Director of Admissions reviewed and revised The Patient Rights document to include language informing individuals of their right to request correction of inaccurate, irrelevant, outdated or incomplete information contained within their records.
2.The Staff Educator in conjunction with the Director of Admissions re-educated the admissions staff on the Patient Rights requirements and the process for addressing requests for record amendments.
MONITORING: The Director of Admissions or designee will conduct monthly audits of 10 admission records to verify that the Patient Rights document contains all required regulatory language and is provided to patients upon admission and signed acknowledgment is maintained in the record. Audit findings will be reported monthly through Performance Improvement Committee for a period of six months.
RESPONSIBLE: Director of Admissions
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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of the facility's Patient Rights, the facility failed to include in its Patient Rights that clients have the right to submit rebuttal data or memoranda to their own records.
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Plan of Correction
ACTIONS:
1.The Director of Admissions reviewed and revised The Patient Rights document to include language informing individuals of their right to submit rebuttal data or memoranda to be maintained within their record.
2. The Staff Educator in conjunction with the Director of Admissions re-educated the admissions staff on the Patient Rights requirements and the process for submitting information for inclusion in the record.
MONITORING: The Director of Admissions or designee will conduct monthly audits of 10 admission records to verify that the Patient Rights document contains all required regulatory language and is provided to patients upon admission and that signed acknowledgement is maintained in their record. Audit findings will be reported monthly through Performance Improvement Committee for a period of six months.
RESPONSIBLE: Director of Admissions
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709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of patient records, the facility failed to develop an individual treatment and rehabilitation plan with a client in two of six records reviewed.
Patient # 1 was admitted to inpatient rehabilitation services on December 24, 2025, and discharged on January 19, 2026. A treatment plan dated 12/30/26 was not signed by staff or the patient.
Patient # 4 was admitted to inpatient rehabilitation services on February 12, 2026, and discharged on March 11, 2026. An undated treatment plan was found in the patient record that was not signed by the patient.
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Plan of Correction
ACTIONS:
1. The Director of Clinical Services will provide education to her clinical staff regarding regulatory requirements for treatment plan development, review, and signature completion including patient participation in treatment planning, patient signature requirements, documentation of refusal or inability to sign and completion of all required staff signatures.
2. The Director of Clinical Services reviewed and revised the treatment plan process to require verification of patient signatures at the time of treatment team review.
MONITORING:
The Director of Performance Improvement will conduct monthly audits of a minimum of 10 treatment records for evidence of patient and staff signatures on treatment plans. Audit results will be reviewed during Performance Improvement Meetings. Compliance below 100% will result in immediate staff re-education and corrective action. Monitoring will continue for 6 months.
All data will be reported monthly through performance improvement committee with appropriate actions taken, up to and including discipline, for any continued noncompliance.
RESPONSIBLE: Director of Clinical Services
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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 a review of patient records and the Interdisciplinary Resident-Centered Care Planning policy, the facility failed to document treatment and rehabilitation plan updates within the regulatory timeframe in one of six records reviewed.
Patient # 6 was admitted to inpatient rehabilitation services on December 19, 2025, and discharged on April 20, 2026. An individual treatment and rehabilitation plan update was completed on January 6, 2026. The next update was due no later than February 6, 2026. There were no individual treatment and rehabilitation plan updates documented after January 6, 2026.
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Plan of Correction
ACTIONS:
1. The Director of Clinical Services will re-educate her clinical staff on regulatory requirements for treatment plan review and update intervals.
2. The Director of Clinical Services and Director of Performance Improvement created and implemented a treatment plan tracking process utilizing a due-date monitoring system to identify upcoming treatment plan review deadlines. Clinical Supervisor will review treatment plan due dates during treatment team meetings to ensure timely completion.
MONITORING:
The Director of Performance Improvement will conduct monthly audits of a minimum of 10 treatment records to verify treatment plan updates are completed within required regulatory timeframes. Results will be reported through the Performance Improvement Committee. Any missed treatment plan review deadlines will be addressed through supervisory follow-up and staff re-education. Monitoring will continue for six months.
RESPONSIBLE: Clinical Supervisor
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of patient records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Patient # 4 was admitted to inpatient rehabilitation services on February 12, 2026, and discharged on March 11, 2026. An undated treatment plan found in the patient record indicated there were to be weekly individual sessions. Documentation of individual sessions is missing in the patient record for the weeks of February 15, 2026, February 22, 2026 and March 1, 2026.
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Plan of Correction
ACTIONS:
1.The Director of Clinical Services and the clinical team members will review treatment plans to ensure counseling interventions and services are individualized, clinically appropriate and implemented in accordance with the patient's treatment plan.
2. The Staff Educator in conjunction with the Director of Clinical Services will re-educate the clinical team regarding counseling services provided align with identified treatment goals, objectives, and interventions.
MONITORING:
The Director of Performance Improvement will conduct monthly audits of a minimum of 10 patient records to verify that counseling services are provided and documented in accordance with the individualized treatment plan. Audit findings will be reported monthly through the Performance Improvement Committee for a period of six-months.
RESPONSIBLE: Director of Clinical Services
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709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of patient records, the facility failed to provide counseling on a regular and scheduled basis in two of six records reviewed.
Patient # 4 was admitted to inpatient rehabilitation services on February 12, 2026, and discharged on March 11, 2026. There was documentation of one individual session conducted on February 13, 2026. There were no individual sessions documentation in the patient record between February 13, 2026 and March 11, 2026.
Patient # 6 was admitted to inpatient rehabilitation services on December 19, 2025, and discharged on April 20, 2026. The last documented individual session was dated February 10, 2026. There were no individual sessions documented in the patient record between February 10, 2026 and April 20, 2026.
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Plan of Correction
ACTIONS:
1. The Director of Clinical Services provided education to Clinical staff regarding the requirement that individual counseling services be provided on regular and scheduled basis, no greater than every 7 days, during treatment. Counselors are responsible for scheduling, completing, and documenting individual counseling sessions within the required timeframe.
2. The Director of Clinical Services along with the Program Manager enhanced the clinical supervision process to include routine review of counseling frequency.
MONITORING:
The Clinical Supervisor or designee will conduct weekly audits of all active patient records to verify that individual counseling sessions are completed and documented at intervals not to exceed seven calendar days. Any identified deficiencies will be addressed through immediate supervisory follow-up and staff education. Audit findings will be reported monthly through the Performance Improvement Committee for a period of six-months.
RESPONSIBLE: Clinical Supervisor
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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 a review of patient records, the facility failed to provide a complete client record, which is to include a record of service in four of six records reviewed.
Patient # 1 was admitted to inpatient rehabilitation services on December 24, 2025, and discharged on January 19, 2026. There are group progress notes for January 2, 2026; however, the record of service for January 2, 2026, is blank.
Patient # 4 was admitted to inpatient rehabilitation services on February 12, 2026, and discharged on March 11, 2026. Group notes are documented for February 13, 2026, February 16, 2026, February 27, 2026, March 3, 2026, March 5, 2026, and March 6, 2026. Documentation of these groups is not reflected in the record of service.
Patient # 5 was admitted to inpatient rehabilitation services on December 27, 2025, and discharged on January 5, 2026. Group notes are documented for December 28, 2026, from 2:30 pm - 3:30 pm, and January 2, 2026, from 2:30 pm - 3:30 pm. Documentation of these groups is not reflected on the record of service.
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Plan of Correction
ACTIONS:
1.The Clinical Supervisor will work with the staff educator to provide re-education to clinical staff regarding the requirement that all services provided to patients must be accurately documented in the clinical record via group notes and records of service. Education will include timely completion of service documentation and ensuring records accurately reflect services delivered.
2. The Director of Clinical Services reviewed and revised the treatment team a meeting process in April 2026 and implemented a standardized treatment team agenda and log to ensure all treatment team meetings are documented and maintained in accordance with regulatory requirements. Treatment team logs are now retained on file for all scheduled meetings.
MONITORING: The Clinical Supervisor or designee will conduct monthly audits of 10 clinical records to verify that services provided are consistently documented in the client record via group notes as well as records of service. Audit findings will be reported monthly through the Performance Improvement Committee for a period of six months.
RESPONSIBLE: Clinical Supervisor
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709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of patient records, the facility failed to provide a complete client record, which is to include progress notes in one of six records reviewed.
Patient # 3 was admitted to inpatient rehabilitation services on February 13, 2026, and discharged on February 21, 2026. The record of service dated February 17, 2026 indicates the patient attended group from 10-11:30 am. There is no group note documented in the patient record.
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Plan of Correction
ACTIONS:
1. The Director of Clinical Services provided reeducation to clinical staff regarding the requirement that all services provided to patients must be supported by a corresponding progress note in the record.
2. The Director of Clinical Services along with the Program Manager enhanced the clinical supervision process to include a routine review of documentation for completeness and timely correction of identified deficiencies.
MONITORING:
The Clinical Supervisor will conduct weekly audits of 10 active patient records to verify that all documented group services have a corresponding progress note in the record. Any identified deficiencies will be address through supervisory follow-up. Audit findings will be reported monthly through the Performance Improvement Committee for a period of six months.
RESPONSIBLE: Clinical Supervisor
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709.53(a)(6) LICENSURE Ind. Tx. Plan
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:
(6) Individualized treatment and rehabilitation plan.
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Observations
Based on a review of patient records, the facility failed to provide a complete client record, which is to include an individualized treatment and rehabilitation plan in one of six records reviewed.
Patient # 6 was admitted to inpatient rehabilitation services on December 19, 2025, and discharged on April 20, 2026. Documentation of an initial treatment and rehabilitation plan was missing from the patient record.
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Plan of Correction
ACTIONS:
1. The Director of Clinical Services provided re-education to clinical staff regarding the requirement that an individualized treatment plan be completed, maintained, and filed in the patient record within 72 hours from the time of admission to the program.
2. The Director of Clinical Services enhanced oversight of treatment planning documentation process to ensure required documentation is present in the clinical record and deficiencies are identified and addressed in a timely manner.
MONITORING:
The Director of Clinical Services or designee will conduct weekly audits of 10 active patient records to verify that an individualized treatment plan is present in the clinical record. Audit findings will be reported monthly through the Performance Improvement Committee for a period of six months.
RESPONSIBLE: Director of Clinical Services
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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 a review of patient records and the Patient Records policy, the facility failed to provide a complete client record, which is to include an individualized treatment and rehabilitation plan in one of six records reviewed.
Per the Patient Records policy, a discharge summary will be entered into the patient ' s record within 30 days after discharge.
Patient # 5 was admitted to inpatient rehabilitation services on December 27, 2026, and discharged on January 5, 2026. Documentation of a discharge summary was missing from the chart upon review on May 12, 2026.
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Plan of Correction
ACTIONS:
1. The leadership team, under the guidance of the Medical Staff, has contracted with transcription service to assist providers with the timely completion of discharge summaries.
2. The Director of Health Information Manager will review discharge summary completion expectations with all applicable providers and clinical staff who have responsibility for discharge summary completion.
MONITORING:
The Director of HIM will conduct weekly audits of discharged client records to verify completion and timeliness of discharge summaries. Audit findings will be reported monthly through the Performance Improvement Committee for a period of six months and ongoing in the Medical Executive Committee
RESPONSIBLE: CMO
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709.53(b) LICENSURE Standardized Forms
709.53. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
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Observations
Based on a review of patient records, the facility failed to maintain patient records on standardized project patient record forms.
Patient # 1 was admitted to inpatient rehabilitation services on December 24, 2025, and discharged on January 19, 2026. There is a note about an incident that occurred on January 17, 2026, signed by a nurse. This note is typed on a plain white piece of paper.
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Plan of Correction
ACTIONS:
1.The DON will review all approved client record forms to ensure only current, standardized forms are utilized throughout the process.
2.Outdated or non-approved forms will be removed from circulation and replaced with approved standardized forms.
3. Nursing staff will be re-educated on the use of approved standardized forms and documentation expectation.
MONITORING:
1.HIM will conduct weekly audits of client records to verify the use of approved standardized forms.
2. Audit findings will be communicated to the DON for follow-up and corrective action as needed.
3. Compliance trends will be reviewed through the Performance Improvement process for a minimum of 90 days.
RESPONSIBLE: Director of Nursing
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