INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 18, 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 five 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 and # 7.
Client # 1 was admitted on May 6, 2021 and was discharged on June 17, 2021. There was no documentation of an informed and voluntary consent from the client for the disclosure of information to the funding source and probation prior to the release of information to these agencies. Authorizations for a funding source was documented in the client record. Correspondence with a probation officer occurred on May 13 and 19, 2021.
Client # 2 was admitted on August 26, 2021 and was discharged on November 23, 2021. There was no documentation of an informed and voluntary consent from the client for the disclosure of information to a lab prior to the release of information to this agency. Documentation of a urinalysis to an outside lab occurred on August 26, 2021.
Client # 3 was admitted on June 15, 2021 and was discharged on November 18, 2021. There was no documentation of an informed and voluntary consent from the client for the disclosure of information to the funding source prior to the release of information to this agency. Authorizations for a funding source was documented in the client record.
Client # 4 was admitted on September 14, 2021 and was still active at the time of the inspection. There was no documentation of an informed and voluntary consent from the client for the disclosure of information to a lab prior to the release of information to this agency. Documentation of a urinalysis to an outside lab occurred on September 14, 2021.
Client # 7 was admitted on August 25, 2021 and was still active at the time of the inspection. There was no documentation of an informed and voluntary consent from the client for the disclosure of information to a lab prior to the release of information to this agency. Documentation of a urinalysis to an outside lab occurred on August 13 and October 12, 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 22, 2021 annual inspection.
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Plan of Correction
Plan of Correction:
All staff were re-educated on February 8th, 2022 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.
Current client records were corrected by the assigned counselors.
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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 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 specific information disclosed.
Client # 3 was admitted on June 15, 2021 and discharged on November 18, 2021. An informed and voluntary consent from the client for the disclosure of information dated June 15, 2021 to an emergency contact 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) (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 one 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 to include a dated signature of the client.
Client # 6 was admitted on May 10, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated May 10, 2021 to a funding agency and emergency contact did not have a valid signature by the client but instead "client signature via zoom" in the signature line.
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.
Current client records were corrected by the assigned counselors.
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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 three of six applicable client records reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and updated at least every 60 days in client record # 3, 5, and 6.
Client # 3 was admitted on June 15, 2021 and was discharged on November 18, 2021. A treatment plan was developed with the client on June 22, 2021. A treatment plan update was due to occur on August 22, 2021 and October 22, 2021 however, there was no other treatment plan update in the client record.
Client # 5 was admitted on September 28, 2021 and was still active at the time of the inspection. A treatment plan was developed with the client on October 19, 2021. A treatment plan update was due to occur on December 19, 2021 however, there was no other treatment plan update in the client record.
Client # 6 was admitted on May 10, 2021 and was still active at the time of the inspection. A treatment plan was developed with the client on May 10, 2021. A treatment plan update was due to occur on July 10, 2021 and September 10, however, the next treatment plan update occurred on December 7, 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 22, 2021 annual inspection.
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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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