INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 20, 2022 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 seven of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 1, 2, 3 4, 5, 6, and # 7.
Client # 1 was admitted on December 2, 2021 and was still active at the time of the inspection. A correspondence that occurred with a lab on December 7, 14, 20, 2021 and January 3, 11, 2022 did not have an informed and voluntary consent from the client for the disclosure of information.
Client # 2 was admitted on November 22, 2021 and was still active at the time of the inspection. A correspondence that occurred with a lab on December 9, 2021 and January 11, 2022 did not have an informed and voluntary consent from the client for the disclosure of information.
Client # 3 was admitted on December 15, 2021 and was still active at the time of the inspection. A correspondence that occurred with a lab on January 5, 2022 did not have an informed and voluntary consent from the client for the disclosure of information.
Client # 4 was admitted on December 13, 2021 and was still active at the time of the inspection. A correspondence that occurred with a lab on September 27, December 14, 20, 2021 and January 5, 11, 2022 did not have an informed and voluntary consent from the client for the disclosure of information.
Client # 5 was admitted on May 17, 2021 and was discharged on July 26, 2021. A correspondence that occurred with a lab on June 29, 2021 and May 18, 2021 did not have an informed and voluntary consent from the client for the disclosure of information.
Client # 6 was admitted on November 9, 2021 and was discharged on January 18, 2022. A correspondence that occurred with a lab on November 9, 30, 2021 and January 11, 2022 did not have an informed and voluntary consent from the client for the disclosure of information.
Client # 7 was admitted on December 1, 2021 and was discharged on January 7, 2022. A correspondence that occurred with a lab on December 7, 14, and 20, 2021 did not have an informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 23, 2021 annual licensing inspection.
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Plan of Correction
All staff were re-educated on February 8th, 2022 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.
Current client records were corrected by the assigned counselors. |
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 two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 5 was admitted on May 17, 2021 and discharged on July 26, 2021. An informed and voluntary consent from the client for the disclosure of information dated May 17, 2021 to a primary care physician did not provide the specific information that was to be disclosed.
Client # 6 was admitted on November 9, 2021 and discharged on January 18, 2022. An informed and voluntary consent from the client for the disclosure of information dated November 9, 2021 to a funding source did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were re-educated on February 8th, 2022 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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709.28 (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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 7 was admitted on December 1, 2021 and was discharged on January 7, 2022. An informed and voluntary consent from the client for the disclosure of information dated December 1, 2021 to a probation officer did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff were re-educated on February 8th, 2022 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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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on one of two applicable client records reviewed, the facility failed to provide documentation of a treatment and rehabilitation plan being updated at least every sixty days in client record # 5.
Client # 5 was admitted on May 17, 2021 and discharged on July 26, 2021. A treatment and rehabilitation plan was developed on May 18, 2021. The next treatment and rehabilitation plan was due no later than July 18, 2021. There was no other treatment plan 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 on February 8th, 2022 the importance of ensuring that treatment plans were updated and reflective of the level of care/ frequency of service that the client is receiving.
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 one of two applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up occurring within a week for a referral or three months by mail for all other discharges.
Client # 5 was admitted on May 17, 2021 and discharged on July 26, 2021. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 23, 2021 annual licensing inspection.
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Plan of Correction
The facility policy and procedure manual was updated to clearly indicate a follow-up occurring for completed treatment discharges three months by mail by the Project Director.
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. |