INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12, 2026, 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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704.11(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 a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that staff persons and volunteers received 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 Department approved curriculum within the regulatory timeframe in one out of three records reviewed.
Employee #1 was hired as the project director/facility director/clinical supervisor on February 05, 2024, and was due to have the communicable disease training no later than February 05, 2025. There was documentation of the completion of the TB/STD training; however, it was not completed until January 08, 2026.
This is a repeat citation from the January 29, 2025 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
A.The Director of Performance Improvement will provide education to the Director of Human Resources and the Director of Outpatient Services on the requirements of Mandatory Communicable Disease training.
MONITORING:
A.The Director of Human Resources, or designee will monitor the required training dates monthly on TB/STD and HIV/AIDS through a tracking process to maintain compliance.
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 Human Resources
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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 a review of seven client records, the facility failed to ensure that informed and voluntary consent to release information forms included the specific information to be disclosed in one out of seven records reviewed.
Client #3 was admitted on May 15, 2025, and was still active at the time of the inspection. The record contained a consent to release to an attorney that was signed and dated August 07, 2025, that was missing the specific information to be disclosed. The facility confirmed disclosure had occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
A.A new consent was obtained for Client #3 on 2/5/2026 to denote what specific information is to be disclosed at the patient's next scheduled outpatient appointment.
B.The Director of Performance Improvement provided education to the Director of Outpatient Services on 2/09/2026 on the requirements of confidentiality, focusing on completion of consents of the specific information disclosed.
C.The Director of Outpatient Services provided one-to-one education to all outpatient counselors on 2/10/2026 on the requirements of confidentiality focusing on completion of consents and information that is being disclosed.
MONITORING:
A. The Director of Outpatient Services will complete a one-time audit of 100% of all active client consent to ensure the purpose of disclosure is specified.
B. The Director of Outpatient Services will complete a monthly audit of 100% of all active client consent to ensure the purpose of disclosure is specified.
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 Outpatient Services
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the purpose of the disclosure in one out of seven records reviewed.
Client #3 was admitted on May 15, 2025, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to an attorney, signed and dated August 07, 2025, did not include the purpose of disclosure. The facility confirmed disclosure had occurred.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
A. A new consent has been obtained on 2/5/2026 for Client #3 to denote what the purpose of disclosure at the patient's next scheduled outpatient appointment.
B. The Director of Performance Improvement provided education on 2/9/2026 to the Director of Outpatient Services on the requirements of confidentiality, focusing on completion of consents on the purpose of the information disclosed.
C. The Director of Outpatient Services provided one-to-one education on 2/10/2026 to all outpatient counselors on the requirements of confidentiality focusing on completion of consents on the purpose of the information disclosed.
MONITORING:
A. The Director of Outpatient Services will complete a one-time audit of 100% of all active client consent to ensure the purpose of the information disclosed.
B. The Director of Outpatient Services will complete a monthly audit of 100% of all active client consent to ensure the purpose of the information disclosed is identified.
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 Outpatient Services
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of seven records reviewed.
Client #3 was admitted on May 15, 2025, and was still active at the time of the inspection. A consent form signed and dated August 07, 2025, for an attorney, did not have documentation that the client was offered a copy of the consent form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
A. A new consent was obtained for Client #3 on 2/5/2026 to denote the client was offered a copy of the consent at the patient's next scheduled outpatient appointment.
B. The Director of Performance Improvement provided education on 2/09/2026 to the Director of Outpatient Services on the requirements of confidentiality, focusing on ensuring documentation is denoted that patient is offered a copy of the consent and that a copy must be maintained in the client chart.
C. The Director of Outpatient Services provided one-to-one education on 2/10/2026 to all outpatient counselors on the requirements of confidentiality focusing on ensuring the client is offered a copy of the consent and that a copy must be maintained in the client chart.
MONITORING:
A. The Director of Outpatient Services will complete a one-time audit of 100% of all active client consent to ensure documentation is denoted that patient is offered a copy of the consent and that a copy must be maintained in the client chart.
B. The Director of Outpatient Services will complete a monthly audit of 100% of all active client consent to ensure documentation is denoted that patient is offered a copy of the consent and that a copy must be maintained in the client chart.
All data will be reported monthly through performance improvement committee with appropriate actions taken, up to and including discipline, for any continued
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709.93(a)(8) LICENSURE Client records
709.93. 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 a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information to be completed monthly, per facility policy, in seven out of seven applicable records reviewed.
Client #1 was admitted on July 30, 2025 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client #2 was admitted on September 18, 2025 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client #3 was admitted on May 15, 2025 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client #4 was admitted on September 30, 2025 and was active at the time of the inspection. There was no documentation of case consultation information in the record.
Client #5 was admitted on June 09, 2025 and was discharged on September 01, 2025. There was no documentation of case consultation information in the record.
Client #6 was admitted on July 10, 2025 and was discharged on October 31, 2025. There was no documentation of case consultation information in the record.
Client #7 was admitted on July 31, 2025 and was discharged on November 06, 2025. There was no documentation of case consultation information in the record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
A. Client #1, Client #2, Client #3 are current clients and have had completed case consultations completed on 2/10/2026 at the patients next scheduled outpatient appointment. Client #4, Client #5, Client #6, and client #7 have been discharged.
B. The Director of Performance Improvement provided education to the Director of Outpatient Services on 2/9/2026 on the requirements of Client Records.
C. The Director of Outpatient Services has provided a one-to-one education to Outpatient counselors on 2/10/2026 on the requirements of the client records.
MONITORING:
A. The Director of Outpatient Services will complete a one-time audit of 100% of active client charts to ensure the client record includes case consultation notes.
B. The Director of Outpatient Services will complete a monthly audit of 100% of active client charts to ensure the client record includes case consultation notes.
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 Outpatient
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