INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 10-11, 2025, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #7 was hired as a counselor on May 8, 2023, and was still in that position at the time of the inspection. This employee was due to have the communicable disease trainings no later than May 8, 2024. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection. Additionally, Employee #7 did complete the HIV/AIDS training on June 29, 2024; however, it was to be completed by May 8, 2024.
This is a repeat citation from the January 23, 2024, and January 12, 2023, annual licensing inspections.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Performance Improvement will provide one to one education to the Director of Human Resources and the Director of Clinical Services on the regulation. Employee #7 will be scheduled for the next available virtual open TB/STD training. Immediately following the training, Employee #7 will forward the certificate to both, the Director of Clinical Services and the Director of Human Resources to ensure follow up and completion. The Director of Human Resources, or designee will monitor the required training dates of TB/STD and HIV/AIDS through a tracking process and ensure direct supervisors have ongoing communication regarding training due dates to maintain compliance. The Director of Human Resources will forward data to the Performance Improvement Committee Quarterly until continued compliance is sustained. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection, the facility failed to restrict the use of heaters that are not permanently mounted or installed. A portable space heater was observed in Office #1 by DDAP staff.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
A freestanding heater was noted in a staff members office during the inspection and was immediately removed by the Director of Plant Operations. The Director of Performance Improvement will provide a one-to-one education to the Director of Plant Operations and Staff Educator on the requirements on Fire Safety, focusing on heaters are not permitted in the facility that are not permanently mounted or installed. The Staff Educator will provide one to one education to all staff members on the requirements of Fire Safety, focusing on heaters are not permitted in the facility that are not permanently mounted or installed. The Director of Plant Operations, or designee will perform monthly audits of facility staff offices for Fire Safety concerns, focusing on heaters are not permitted that are not permanently mounted or installed. The Director of Plant Operations, or designee will continue monthly audits until continued compliance is sustained. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of detox and residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.
Per the requirement in the DDAP Licensing Alert 02-21 the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice
Client # 5 was admitted to the inpatient non-hospital detoxification activity on January 1, 2025 and was discharged against medical advice on January 6, 2025. There was no documentation that the emergency contact was notified of the client's discharge from the facility against medical advice as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Performance Improvement will provide one to one education to the Director of Nursing and Staff Educator on the regulation. Client #5 discharged. The Staff Educator will provide one to one education to all Nurses on the requirements ensure that the emergency contact has been notified no later than 12 hours of the patient leaving against medical advice. The Director of Nursing, or designee will complete monthly audits on all patient charts who leave the facility against medical advice to ensure that the emergency contact has been notified no later than 12 hours of the patient leaving. The Director of Nursing or designee will continue monthly audits until continued compliance is sustained. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to complete annual written staff performance evaluations, copies of which shall be reviewed and signed by the employee in six out of six applicable staff personnel records. Additionally, the facility's staffing performance evaluation policy notes "each employee, including contract and credentialed staff, will be evaluated after completing their initial probationary period (approximately 3 months after hire/transfer date) and then on an annual basis throughout the duration of the employment relationship. "
Employee #1 was hired as the Project Director on June 16, 2024, and was still in that position at the time of the inspection. There was no documentation to verify that a probationary performance evaluation was completed.
Employee #2 was hired as the Facility Director on April 1, 2024, and was still in that position at the time of the inspection. There was no documentation to verify that a probationary performance evaluation was completed.
Employee #3 was hired as the Clinical Supervisor on August 26, 2024, and was still in that position at the time of the inspection. A probationary performance evaluation was completed for this employee on November 17, 2024; however; there was no documentation that it had be reviewed with the employee.
Employee #4 was hired as a Counselor on April 16, 2024, and was still in that position at the time of the inspection. There was no documentation to verify that a probationary performance evaluation was completed.
Employee # 5 was hired as a Counselor on August 13, 2023, and was still in that position at the time of the inspection. An annual written evaluation was completed for this employee on October 1, 2024, however; there was no documentation that it had been reviewed with the employee.
Employee #7 was hired as a Counselor on May 8, 2023, and was still in that position at the time of the inspection. An annual written evaluation was completed for this employee on December 12, 2024, however; there was no documentation that it had been reviewed with the employee.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Performance Improvement will provide one to one education to the Director of Human Resources and Director of Clinical Services on the completion of staff performance evaluations. Employee #1, Employee #2, and Employee #4 will have one time 90-day evaluation completed with signature by 3/31/2025. Employee #3 is no longer employed. Employee #5 and Employee #7 will have an annual evaluation completed with signature by 3/31/2025. The Director of Human Resources, or designee will complete a one-time audit on all active staff members to ensure completion of staff performance evaluations per regulation and facility policy and procedure, including signatures. The Director of Human Resources, or designee will monitor the written staff performance evaluations through a tracking process and ensure direct supervisors have ongoing communication regarding 90 day and annual staff performance evaluations to maintain compliance. The Director of Human Resources will continue monthly audits until continued compliance is sustained. |
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.
|
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. The consent must be in writing and include, but not be limited to: specific information disclosed. This was observed in three out of fourteen records reviewed.
Client #11 was admitted on July 14, 2024, and was discharged on August 29, 2024. A release of information form, for a pharmacy, was signed and dated on August 29, 2024; however, it did not document what information was being disclosed.
Client #13 was admitted on July 10, 2024, and was discharged on August 20, 2024. A release of information form, for a pharmacy, was signed and dated on August 20, 2024; however, it did not document what information was being disclosed.
Client #14 was admitted on August 12, 2024, and was discharged on September 11, 2024. A release of information form, for a pharmacy, was signed and dated on September 11, 2024; however, it did not document what information was being disclosed.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Performance Improvement will provide education to the Director of Nursing and the Staff Educator on the requirements of Confidentiality, focusing on completion of consents. Client #11, Client #13, and Client #14 were discharged. The Staff Educator will provide one to one education to all Nurses on the requirements of Confidentiality focusing on completion of consents and information that is being disclosed. The Director of Nursing, or designee will complete an audit of 100% of active patient consents to ensure the purpose of disclosure is specified. The Director of Nursing, or designee will continue monthly audits until continued compliance is sustained. |
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.
|
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. The consent must be in writing and include, but not be limited to purpose of disclosure This was observed in three out of fourteen records reviewed.
Client #11 was admitted on July 14, 2024, and was discharged on August 29, 2024. A release of information form, for a pharmacy, was signed and dated on August 29, 2024; however, it did not document the purpose of the disclosure.
Client #13 was admitted on July 10, 2024, and was discharged on August 20, 2024. A release of information form, for a pharmacy, was signed and dated on August 20, 2024; however, it did not document the purpose of the disclosure.
Client #14 was admitted on August 12, 2024, and was discharged on September 11, 2024. A release of information form, for a pharmacy, was signed and dated on September 11, 2024; however, it did not document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Performance Improvement will provide education to the Director of Nursing and Staff Educator on the requirements of Confidentiality, focusing on completion of consents. Client #11and Client #13, and Client #14 were discharged. The Staff Educator will provide one to one education to all Nurses on the requirements of Confidentiality focusing on completion of consents and purpose of the disclosure. The Director of Nursing, or designee will complete an audit of 100% of active patient consents to ensure the purpose of disclosure is specified. The Director of Nursing, or designee will perform monthly audits of consents to ensure the purpose of disclosure is specified. The Director of Nursing, or designee will continue monthly audits until continued compliance is sustained. |
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.
|
Observations
Based on a review of detox and residential client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in four out of fourteen client records reviewed.
Client #4 was admitted on February 3, 2025, and was discharged on February 9, 2025. Three releases of information were completed on February 3, 2025, for a healthcare provider, a hospital and an emergency contact, none of these contained documentation that a copy had been offered to the client.
Client #11 was admitted on July 14, 2024, and was discharged on August 29, 2024. Two releases of information were completed on July 14, 2024, for a friend and a payor, neither contained documentation that a copy had been offered to the client. Additionally, a release was completed on August 29, 2024, for a pharmacy, it did not contain documentation that a copy was offered to the client.
Client #13 was admitted on July 10, 2024, and was discharged on August 20, 2024. A release of information form, for a pharmacy, was signed and dated on August 20, 2024; however, it did not document that a copy was offered to the client.
Client #14 was admitted on August 12, 2024, and was discharged on September 11, 2024. A release of information form, for a pharmacy, was signed and dated on September 11, 2024; however, it did not document that a copy was offered to the client.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Performance Improvement will provide education to the Director of Admissions and Staff Educator on the requirements of Confidentiality, focusing on ensuring consents contain documentation that a copy has been offered to the patient. Client #4, Client #11, Client #13, and Client #14 were discharged. The Staff Educator will provide one to one education to all Admission Staff on the requirements of Confidentiality focusing on ensuring consents contain documentation that a copy has been offered to the patient. The Director of Admissions, or designee will complete an audit of 100% of active patient consents ensuring consents contain documentation that a copy has been offered to the patient. The Director of Admissions, or designee will perform monthly audits on ensuring consents contain documentation that a copy has been offered to the patient. The Director of Admissions, or designee will continue monthly audits until continued compliance is sustained. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of three applicable record reviewed.
Client #11 was admitted on July 14, 2024, and was discharged August 29, 2024. A treatment plan was completed on July 16, 2025, and the next update was due no later than July 29, 2024 ; however, there was no documentation to verify that an additional treatment plan had been completed.
Client #12 was admitted on July 11, 2024, and was discharged August 9, 2024. A treatment plan was completed on July 17, 2024, and the next update was due no later than August 1, 2024 ; however, there was no documentation to verify that an additional treatment plan had been completed.
Client #13 was admitted on July 10, 2024, and was discharged August 20, 2024. A treatment plan was completed on July 23, 2024, and the next update was due no later than August 7, 2024 ; however, there was no documentation to verify that an additional treatment plan had been completed.
This is a repeat citation from the January 23, 2024, and January 12, 2023, annual licensing inspections.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Performance Improvement will provide a one-to-one education to the Director of Clinical Services and Staff Educator on the requirements of treatment plans for all active patients, focusing on treatment plan updates and the required timeframes. Client #11, Client #12, and Client #13 were discharged. The Staff Educator will provide one to one education to all Clinical staff members on the requirements of treatment plans for all active patients, focusing treatment plan updates and the required timeframes. The Director of Clinical Services, or designee will complete an audit of 100% of active patient treatment plan updates to ensure completion within the required timeframes. The Director of Clinical Services, or designee will perform monthly audits of active patient charts to ensure treatment plan updates are completed timely. The Director of Clinical Services, or designee will forward data to the Performance Improvement Committee monthly until continued compliance is sustained. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of residential client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in two out of six applicable records reviewed.
Client #11 was admitted on July 14, 2024, and was discharged on August 29, 2024, The treatment plan dated July 16, 2024, indicated one individual therapy session, one time a week for thirty minutes. There was no documentation to verify individual sessions occurred for the week of July 21-27, 2024. Additionally, there was no documentation to verify individual sessions occurred for the period of August 4-24, 2024.
Client #13 was admitted on July 10, 2024, and was discharged on August 20, 2024. The treatment plan dated July 23, 2024, indicated weekly individual sessions. There was no documentation to verify that the individual sessions occurred for the period of July 23-August 18, 2024.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Performance Improvement will provide a one-to-one education to the Director of Clinical Services and Staff Educator on the requirements of an individual treatment plan for all active patients, focusing on documentation on treatment type. Client #11 and Client #13 were discharged. The Staff Educator will provide one to one education to all Clinical staff members on the requirements of an individual treatment plan for all active patients, focusing on documentation on treatment type. The Director of Clinical Services, or designee will complete an audit of 100% of active patient treatment plans to ensure documentation of treatment type. The Director of Clinical Services, or designee will perform monthly audits of active patient charts to ensure documentation of active patient type is on the treatment plan. The Director of Clinical Services, or designee will continue monthly audits until continued compliance is sustained. |
709.53(a)(3) LICENSURE Records of Service
709.53. 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.
|
Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which is to include a record of services provided. There were no records of services provided in seven out of seven client files reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Performance Improvement will provide a one-to-one education to the Director of Clinical Services and Staff Educator on the requirements of the Record of Service. The Staff Educator will provide one to one education to all unit staff members on the requirements of the Record of Service. The Director of Clinical Services, or designee will complete an audit of 100% of active patient charts to ensure the Record of Service is present. The Director of Clinical Services, or designee will perform monthly audits of active patient charts to ensure completion of Record of Service. The Director of Clinical Services, or designee will continue monthly audits until continued compliance is sustained. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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.
|
Observations
Based on a review of residential client records, the facility failed to provide a complete client record, which is to include follow-up information in one of three applicable client records reviewed.
The facility's policy is to follow-up with discharged clients, regardless of discharge status, within three months of discharge.
Client #12 was admitted on July 11, 2024, and was discharged on August 9, 2024. There was no documentation to verify that a follow-up contact had taken place.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Performance Improvement will provide a one-to-one education to the Director of Clinical Services and Staff Educator on the requirements of follow-up with discharged clients, regardless of discharge status. Client #12 was discharged. The Staff Educator will provide one to one education to all Clinical staff members on the requirements of follow-up with discharged clients, regardless of discharge status. The Director of Clinical Services, or designee will perform monthly audits of patient charts to ensure documentation requirements of follow-up with discharged clients, regardless of discharge status. The Director of Clinical Services, or designee will continue monthly audits until continued compliance is sustained. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on the review of client records, the facility failed to comply with plans of correction approved by the Department.
A plan of correction for mandatory communicable disease training were submitted and approved by the Department for the January 23, 2024, and January 12, 2023, annual licensing inspections. Mandatory communicable disease training was again about to be a deficiency in the February 11, 2025 licensing inspection.
A plan of correction for treatment plan updates were submitted and approved by the Department for the January 23, 2024, and January 12, 2023, annual licensing inspections. Treatment plan updates was again about to be a deficiency in the February 11, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Performance Improvement will provide one to one education to the Director of Human Resources and the Director of Clinical Services on the repeat violations on communicable disease training and Treatment Plan Updates. The Director of Human Resources, or designee will monitor the required training dates of TB/STD and HIV/AIDS through a tracking process and ensure direct supervisors have ongoing communication regarding training due dates to maintain compliance. The Director of Human Resources will forward data to the Performance Improvement Committee Quarterly until continued compliance is sustained. The Director of Clinical Services or designee will monitor treatment plan updates through a tracking process to ensure treatment plan updates are within regulation. The Director of Clinical Services will forward data to the Performance Improvement Committee Quarterly until continued compliance is sustained. |