INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on August 6, 2025, 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. The following deficiencies were identified during this investigation:
|
Plan of Correction
|
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of patient records, the facility failed to adhere to its written procedures for the management of treatment/rehabilitation services for patients.
The facility ' s " Patient Sexual Familiarity Prevention Guidelines " policy notes " G. When an occurrence of sexual familiarity is discovered, steps should be taken to prevent recurrence. A preventative approach should be instituted as part of the patient ' s treatment plan. "
DDAP staff reviewed two patient files of individuals that had been involved in sexual familiarity. There was no documentation in the patient records to indicate amended treatment plans to address these issues.
These findings were reviewed with facility staff during the investigation.
|
Plan of Correction
Action:
Clinical staff were provided with re-education on August 20, 2025, by the Director of Clinical Services to ensure that all treatment plan updates are completed by policy and regulation representative of changes in patient condition including prevention of sexual familiarity.
Monitoring:
The Director of Clinical Services, Clinical Supervisor, or designee will audit no less than 50% of active patient charts each month to ensure treatment plans and treatment plan updates are representative of patient need and changes in patient condition through the course of treatment. Audit results will be reported monthly to the PI Committee until evidence of compliance is sustained.
|
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory, fifteen-day, timeframe in two of four patient records reviewed.
Client #2 was admitted on July 17, 2025, and was still active at the time of the investigation. A treatment plan was completed on July 20, 2025, and the next update was due no later than August 4, 2025; however, there was no documentation to verify that an additional treatment plan had been completed.
Client #4 was admitted on June 13, 2025, and was still active at the time of the investigation. A treatment plan was completed on June 17, 2024, and the next update was due no later than July 2, 2025; however, the next treatment plan documented was completed July 15, 2025.
These findings were reviewed with facility staff during the investigation.
|
Plan of Correction
Action:
- The Director of Performance Improvement will contact Department of Drug and Alcohol Program by 8/22/2025 to amend the Data Collection Report for activity 823 to reference the program as a 30 day stay program. In the interim 15-day treatment plan updates will occur for each patient until the Data Collection Report is changed to reflect a 30 day stay program.
- Clinical staff will be provided with education by the Director of Clinical Services to ensure that all treatment plans updates are completed by policy and regulation within a timeframe no greater than every 15 days or as necessary based on patient condition until the Data Collection Report is changed to reflect a 30 day stay program.
Monitoring:
- The Director of Clinical Services, Clinical Supervisor, or designee will audit no less than 50% of active patient charts each month to ensure treatment plans and treatment plan updates are representative of patient need and changes in patient condition through the course of treatment. Audit results will be reported monthly to the PI Committee until evidence of compliance is sustained.
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of four applicable records reviewed.
Client #1 was admitted on July 15, 2025, and was still active at the time of the investigation. A treatment plan dated July 24, 2025, indicated one individual therapy session per week and five group sessions per week. During the week of July 27-August 2, 2025, only two group sessions were documented in the patient record.
Client #2 was admitted on July 17, 2025, and was still active at the time of the investigation. A treatment plan dated July 20, 2025, indicated one individual therapy session per week and five group sessions per week. During the week of July 27-August 2, 2025, no individual sessions were documented in the patient record.
Client #4 was admitted on June 13, 2025, and was still active at the time of the investigation. A treatment plan dated July 15, 2025, indicated one individual therapy session per week and five group sessions per week. During the week of July 20-July 26, 2025, only two group sessions were documented in the patient record.
These findings were reviewed with facility staff during the investigation.
|
Plan of Correction
Action:
- Clinical staff were provided with re-education on August 20, 2025, by the Director of Clinical Services to review regulation 709.52 (c) to ensure that counseling services are provided according to the individual treatment and rehabilitation plan. Training included review of the requirement to ensure interventions included in the treatment plan, including group and individual therapy, are documented in the patient medical record.
Monitoring:
- The Director of Clinical Services, Clinical Supervisor, or designee will audit no less than 50% of active patient charts each month to ensure the medical record represents documentation of the treatment interventions outlined in the treatment plan, specifically group and individual notes. Audit results will be reported monthly to the PI Committee until evidence of compliance is sustained.
|