INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3, 2011 through January 6, 2011 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on January 31, 2011.
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Plan of Correction
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709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records and a review with the project director and facility director, the facility failed to document aftercare plans in three of four short-term detoxification discharge records reviewed.
The findings include:
Eight short-term detoxification client records were reviewed on January 6, 2011. Aftercare plans were required in all four of the short-term detoxification client records reviewed, #5, 6, 7 and 8. Per the facility's policy and procedure, all clients will obtain an aftercare plan before discharge. An interview was conducted with the project director and facility director and it was confirmed that aftercare plans were not documented in three of the four short-term detoxification discharge records.
Client #5 was admitted on September 1, 2010 and discharged on September 2, 2010. As of the date of the inspection there was no documentation of the client's aftercare plan in record reviewed.
Client #6 was admitted on September 10, 2010 and discharged on September 12, 2010. As of the date of the inspection there was no documentation of the client' s aftercare plan in record reviewed.
Client #7 was admitted on September 8, 2010 and discharged on September 11, 2010. As of the date of the inspection there was no documentation of the client ' s aftercare plan in record reviewed.
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Plan of Correction
The Director of Social Services (DSS) will educate the Social Workers on aftercare planning. A focus of this education will be on making sure all patients discharged from treatment have an aftercare plan, prior to discharge. The DSS will educate staff at the February staff meeting. The completion date for this corrective action is 14 February 2011. The deficiency will be addressed through supervision, education, and additional training, if necessary. The Director of Social Services will audit medical records to monitor continued compliance. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review of client records and a review with the project director and facility director, the facility failed to document follow-up information in four of four short-term detoxification discharge records reviewed.
The findings include:
Nineteen client records reviewed and out of those nineteen, eight were short-term detoxification clients. The short-term detoxification client records were reviewed on January 6, 2011. Follow-up information were required in all four of the short-term detoxification client records reviewed, #5, 6, 7 and 8. Per the facility's policy and procedure, all clients will either be contacted within 7 days if being referred or within 3 months of their discharge date. An interview was conducted with the project director and facility director and it was confirmed that follow-up information was not documented in four of the four short-term detoxification discharge records.
Client #5 was admitted on September 1, 2010 and discharged on September 2, 2010. As of the date of the inspection there was no documentation of the client's follow-up information in the record reviewed. The follow-up should have taken place by December 2, 2010.
Client #6 was admitted on September 10, 2010 and discharged on September 12, 2010. As of the date of the inspection there was no documentation of the client's follow-up information in the record reviewed. The follow-up should have taken place by December 12, 2010.
Client #7 was admitted on September 8, 2010 and discharged on September 11, 2010. As of the date of the inspection there was no documentation of the client's follow-up information in the record reviewed. The follow-up should have taken place by December 11, 2010.
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Plan of Correction
The Director of Social Services (DSS) will educate the Social Workers on patient follow-ups. A focus of this education will be on making sure all patients discharged from the facility will either be contacted within 7 days, if being referred, or within 3 months of their discharge date. The DSS will educate staff at the February staff meeting. The completion date for this corrective action is 14 February 2011. The deficiency will be addressed through supervision, education, and additional training, if necessary. The Director of Social Services will audit medical records to monitor continued compliance.
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