INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23, 2021 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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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 six of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client record # 2, 3, 4, 5, 6, and 7.
Client # 2 was admitted on November 16, 2020 and was still active at the time of the inspection. There was not an informed and voluntary consent from the client for the disclosure of information for a funding source. A review of the client record indicated a funding source for the client.
Client # 3 was admitted on December 10, 2020 and was still active at the time of the inspection. There was not an informed and voluntary consent from the client for the disclosure of information for a funding source. A review of the client record indicated a funding source for the client.
Client # 4 was admitted on December 30, 2020 and was still active at the time of the inspection. There was not an informed and voluntary consent from the client for the disclosure of information for a funding source. A review of the client record indicated a funding source for the client.
Client # 5 was admitted on April 27, 2020 and was discharged on July 2, 2020. There was not an informed and voluntary consent from the client for the disclosure of information for a funding source. A review of the client record indicated a funding source for the client.
Client # 6 was admitted on August 19, 2020 and was discharged on November 6, 2020. There was not an informed and voluntary consent from the client for the disclosure of information for a funding source. A review of the client record indicated a funding source for the client.
Client # 7 was admitted on July 9, 2020 and was discharged on September 21, 2020. There was not an informed and voluntary consent from the client for the disclosure of information for a funding source. A review of the client record indicated a funding source for the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were re-educated on not only the standard of receipt of all informed and voluntary consents but as to the requirement of specific consents such as disclosure of information for a funding source.
Ongoing weekly, random file audits will occur that the Project Director will supervise and track. Results will be presented at weekly staff meetings and/or monthly staff supervisions with re-education as necessary throughout the monitoring process.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on three of seven client records reviewed, the facility failed to provide a complete client record to include a record of services.
Client # 1 was admitted on July 14, 2020 and was still active at the time of the inspection. There was no record of services documented in the client record.
Client # 3 was admitted on December 10, 2020 and was still active at the time of the inspection. Progress notes for services dated December 22, January 14, 21, 28, February 5, 15, March 4, and 11 were in the client record however, the client record of service did not reflect these services.
Client # 4 was admitted on December 30, 2020 and was still active at the time of the inspection. Progress notes for services dated January 19, 20, 22, 25, 27, 29 February 1, 3, 5, 8, 10, 18, 17, 19, 26, March 3, 4, 11, 12, and 18 were in the client record however, the client record of service did not reflect these services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors were re-educated on the importance of ensuring services delivered were not just documented on billing slips and progress notes, but on a record of service as well.
Ongoing weekly, random file audits will occur that the Project Director will supervise and track. Results will be presented at weekly staff meetings and/or monthly staff supervisions with re-education as necessary throughout the monitoring process.
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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 three of three applicable client records reviewed, the facility failed to provide documentation of case consultation notes in accordance with the facility policy and procedure. Per the facility manual, case consultations are to occur at least once during treatment.
Client # 5 was admitted on April 27, 2020 and was discharged on July 2, 2020. There was no documentation of a case consultation in the client record.
Client # 6 was admitted on August 19, 2020 and was discharged on November 6, 2020. There was no documentation of a case consultation in the client record.
Client # 7 was admitted on July 9, 2020 and was discharged on September 21, 2020. There was no documentation of a case consultation in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure will be reviewed surrounding case consultations and all counselors will be educated upon completion.
Ongoing weekly, random file audits will occur that the Project Director will supervise and track. Results will be presented at weekly staff meetings and/or monthly staff supervisions with re-education as necessary throughout the monitoring process.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on three of three applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual of occurring within a week for a referral or three months by mail for all other discharges.
Client # 5 was admitted on April 27, 2020 and was discharged on July 2, 2020. There was no documentation of follow-up information in the client record.
Client # 6 was admitted on August 19, 2020 and was discharged on November 6, 2020. There was no documentation of follow-up information in the client record.
Client # 7 was admitted on July 9, 2020 and was discharged on September 21, 2020. There was no documentation of follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors were re-educated to ensure a copy of the follow up letter that is sent also be placed into the client file.
Ongoing weekly, random file audits will occur that the Project Director will supervise and track. Results will be presented at weekly staff meetings and/or monthly staff supervisions with re-education as necessary throughout the monitoring process.
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