INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14-15, 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 fifteen 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. Employee #1 was hired as the project director on June 16, 2024, and was due to have the communicable disease training no later than June 16, 2025. There was no documentation for the completion of the HIV/AIDS or the TB/STD training as of the date of the inspection.Employee #5 was hired as a counselor aide on September 11, 2023, and was promoted to counselor on January 12, 2025. She was due to have the communicable disease trainings no later than September 11, 2025. There was no documentation in the personnel file for the completion of the HIV/AIDS or the TB/STD training as of the date of the inspection.Employee #8 was hired as a counselor on May 08, 2023, and was due to have the communicable disease training no later than May 08, 2024. There was no documentation for the completion of the TB/STD training as of the date of the inspection. Employee #10 was hired as a HR rep on May 14, 2023, and was due to have the communicable disease training no later than May 14, 2025. There was no documentation for the completion of the HIV/AIDS or the TB/STD training as of the date of the inspection. This is a repeat citation from the January 12, 2023, January 23, 2024, and the February 11, 2025, licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS: The Director of Performance 1.The Director of Performance Improvement will provide education to the Director of Human Resources on the requirements of Mandatory Communicable Disease training by 2/16/2026
2. Roxbury Treatment Center will submit an internal training plan for DDAP approval by 2/25/2026 on HIV/AIDS, Tuberculosis, Sexually Transmitted diseases and other health related topics. Following DDAP approval Roxbury will train all outstanding staff within 30 days.
MONITORING:
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) 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 a review of client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information in three of the fourteen records reviewed. Client #5 was admitted to the detoxification level of care on August 08, 2025, and discharged August 13, 2025. There was documentation that information was disclosed to an emergency contact on August 13, 2025; however, the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.Client #10 was admitted to the inpatient level of care on admitted on November 08, 2025, and was still active at the time of the inspection. There was documentation that information was disclosed to the client's probation officer on November 24, 2025, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.Client #13 was admitted to the level of care on May 01, 2025, and discharged on May 30, 2025. There was documentation that information was disclosed to a family friend on May 19, 2025, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
A.Client #5, Client #10 and Client #13 have all been discharged from the facility.
B.The Director of Performance Improvement has collaborated with Director of Clinical Services, Director of Admissions and Director of Nursing on 2/11/2026 to provide education to their respective staff members on the requirements of confidentiality, focusing on obtaining informed and voluntary consent from the client for the disclosure of information contained in the client record.
MONITORING:
The Director of Performance Improvement or designee will complete a monthly audit of a minimum of 10 patient charts, focusing on obtaining informed and voluntary consent from the clients for the disclosure of information contained in the client record.
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 Performance Improvement
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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 review of client records, the facility failed to obtain an informed and voluntary consent which included the specific information to be disclosed in three out fourteen records reviewed. Client #8 was admitted to the inpatient level of care on November 05, 2025, and was still active at the time of the inspection. A release of information form for an emergency contact was signed and dated on November 05, 2025; however, it did not include the specific information to be disclosed.Client #9 was admitted to the inpatient level of care on November 17, 2025, and was still active at the time of the inspection. A release of information form for a pharmacy, an outside hospital, and the funding source, was dated on November 17, 2025; however, it did not include the specific information to be disclosed. Client #13 was admitted to the inpatient level of care on May 01, 2025, and discharged on May 30, 2025. A release of information form for a pharmacy was dated on May 01, 2025; however, it did not include the specific information to be disclosed. This is a repeat citation from the February 10-11, 2025 licensing inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
ACTIONS:
1. A new consent was obtained for Client #8, Client #9 on 1/15/2026 to denote what specific information is to be disclosed. Client #13 was discharged.
2. The Director of Performance Improvement collaborated with Director of Clinical Services, Director of Admissions and Director of Nursing on 2/11/2026 to provide education to their respective staff members on the requirements of confidentiality, focusing on specific information disclosed.
MONITORING:
The Director of Performance Improvement or designee will complete a monthly audit a minimum of 10 patient charts, focusing on specific information disclosed.
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 Performance Improvement
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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 two out of fourteen records reviewed.Client #9 was admitted to the inpatient level of care on November 17, 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 a pharmacy, a community hospital, the single county authority, and a mental health facility, were all signed and dated November 17, 2025, that did not include the purpose of disclosure. Client #13 was admitted to the inpatient level of care on May 01, 2025, and discharged May 30, 2025. An informed and voluntary consent from the client for the disclosure of information to an outside pharmacy, did not include the purpose of disclosure. This is a repeat citation from the February 10-11, 2025, licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
1. A new consent was obtained for Client #9 on 1/15/2026 to denote what the purpose of information is to be disclosed. Client #13 was discharged.
2. The Director of Performance Improvement collaborated with Director of Clinical Services, Director of Admissions and Director of Nursing on 2/11/2026 to provide education to their respective staff members on the requirements of confidentiality, focusing on purpose of disclosure.
MONITORING
The Director of Performance Improvement or designee will complete a monthly audit a minimum of 10 patient charts, focusing on focusing on purpose of disclosure.
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 Performance Improvement
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included the dated signature of the client in two out of fourteen records reviewed. Client #9 was admitted to the inpatient level of care on November 17, 2025, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record dated November 17, 2025, for a funding source, a mental health facility, a pharmacy, a community hospital, and the single county authority had a witness signature, but did not include the dated signature of the client. The facility confirmed disclosure had occurred. Client #13 was admitted to the inpatient level of care on May 01, 2025, and discharged on May 30, 2025. An informed and voluntary consent from the client for the disclosure of information contained in the client record dated May 30,2025, for a pharmacy, had a witness signature, but did not include the dated signature of the client. The facility confirmed disclosure had occurred.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
1. A new consent wasobtained for Client #9 on 1/15/2026 to ensure the client has a signature with date. Client #13 was discharged.
2. The Director of Performance Improvement collaborated with Director of Clinical Services, Director of Admissions and Director of Nursing on 2/11/2026 to provide education to their respective staff members on the requirements of confidentiality, focusing on obtaining signature and date requirements.
MONITORING:
The Director of Performance Improvement or designee will complete a monthly audit a minimum of 10 patient charts, focusing on signature and date requirements.
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 Performance Improvement
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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 eight out of fourteen client records reviewed. Client #2 was admitted to the detoxification level of care on September 29, 2025, and was discharged on September 30, 2025. A consent form signed and dated September 29, 2025, for the funding source, the emergency contact, a medical center, and a pharmacy, did not have documentation that the client was offered a copy of the consent form.Client #5 was admitted to the detoxification level of care on August 08, 2025, and discharged on August 13, 2025. A consent form signed and dated August 08, 2025, for a hospital, did not have documentation that the client was offered a copy of the consent form. Client #6 was admitted to the detoxification level of care on September 16, 2025, and discharged on September 16, 2025. A consent form signed and dated September 16, 2025, for a pharmacy, a hospital, the emergency contact, and a primary physician, did not have documentation that the client was offered a copy of the consent form. Client #8 was admitted to the inpatient level of care on November 05, 2025, and was still active at the time of the inspection. A consent form signed and dated November 05, 2025, for the emergency contact, a hospital, a pharmacy, county probation, and the single county authority, did not have documentation that the client was offered a copy of the consent form. Client #9 was admitted to the inpatient level of care on November 17, 2025, and was still active at the time of the inspection. A consent form dated November 17, 2025, for a funding source, a pharmacy, a community hospital, a mental health facility, and the single county authority. Client #10 was admitted to the inpatient level of care on November 08, 2025, and was still active at the time of the inspection. A consent form signed and dated November 08, 2025, for a pharmacy, a medical center, the emergency contact, the funding source, and an urgent care center, did not have documentation that the client was offered a copy of the consent. Client #11 was admitted to the inpatient level of care on November 19, 2025, and was still active at the time of the inspection. A consent form signed and dated November 19, 2025, to the funding source, the emergency contact, a pharmacy, mental health hospital, medical center, and the referral source, did not have documentation that the client was offered a copy of the consent. Client #14 was admitted to the inpatient level of care on May 05, 2025, and discharged on June 03, 2025. A consent form signed and dated June 02, 2025, to a recovery house, did not have documentation that the client was offered a copy of the consent. This is a repeat citation from the February 10-11, 2025 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
1.A new consent was obtained for Client #8 #9, #10, and #11 on 1/15/2026 to ensure the client has been offered a copy of the consent. Client #2, # 5, 6, and #14 was discharged.
2.The Director of Performance Improvement collaborated with Director of Clinical Services, Director of Admissions and Director of Nursing on 2/11/2026 to provide education to their respective staff members on the requirements of confidentiality, focusing on ensuring the client was offered a copy and a copy is maintained in the client record.
MONITORING:
The Director of Performance Improvement or designee will complete a monthly audit a minimum of 10 patient charts, focusing on ensuring the client was offered a copy and a copy is maintained in the client record.
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 Performance Improvement
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative documents, the facility failed to file an unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel. Based on a review of the facility ' s unusual incidents there was documentation that emergency personnel were at the facility on December 27, 2025. The facility reported the incident to the Department on January 07, 2026; however, it was not within the regulatory three business day timeframe.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ACTIONS:
1. The Director of Performance Improvement collaborated with Director of Clinical Services and Director of Nursing on 2/11/2026 to provide education to their respective staff members on the requirements of reporting of unusual incidents, focusing on timeframes and specific events that occur to ensure timely reporting as required.
2. The PI Director and the Risk Manager have created a log on 2/11/2026 for tracking the submission of those required events to ensure timely reporting.
MONITORING:
1. Each weekday in morning operations meeting, the Risk Manager or Designee will review all incidents from the past 24 hours to ensure all events within the program are reported timely.
2. The Director of Performance Improvement or designee will complete a weekly audit a minimum of 2 days week of SUD nursing report, focusing on capturing incidents or unusual events against DDAP requirements to ensure timely reporting.
3. Through these processes, any event without corresponding report to DDAP as required will be immediately reported by the PI Director or designee.
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 Performance Improvement
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