INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 4, 2022 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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709.26 (a) LICENSURE Personnel Management
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
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Observations
Based on a review of the Corrective Action Process policy and staff interviews, the facility failed to follow the enforcement guidelines of this policy which states that supervisory personnel are responsible for the enforcement of the facility rules and regulations and the handling of any corrective action that may be required.
After a supervisor was made aware of a potential major work rule violation, there was no internal investigation conducted.
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Plan of Correction
Supervisory staff will be provided re-education on ensuring the HR Director is notified of any reported allegations of staff misconduct and that the investigation process and associated documentation required is thoroughly completed. This re-education will occur on or before 11/2/22. The Director of Clinical Services and Director of HR will maintain oversight of this process by reviewing to ensure all necessary action steps, follow up, and documentation is completed for all reported allegations of clinical staff misconduct. |