INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 31, 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in one out of two employee records reviewed. The facility's policy is to complete a training plan at the time of an employees hire and then annually by the anniversary of the employees hire date.
Staff #1 was hired on February 5, 2024, as the project/facility director and was still in the position as of the date of the inspection. There was no documentation that a training plan was completed for this staff.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Director of Performance Improvement will provide education to the Director of Human Resources and the Director of Outpatient on the requirements of the training plan for staff members. Staff #1 signed a training plan; this was placed in the employee file. The Director of Human Resources, or designee will ensure all new employees receive and sign a training plan within the New Hire Orientation. The Director of Human Resources, or designee will monitor the training plans through a tracking process and ensure direct supervisors have ongoing communication regarding training plan due dates to maintain compliance. The Director of Human Resources will forward data to the Performance Improvement Committee Quarterly until continued compliance is sustained. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical site inspection, it was determined that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The fire extinguisher located in the hallway outside of the facility entrance was last inspected in May 2023.
This finding was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
The Director of Performance Improvement has provided a one-to-one education to the Director of Outpatient Services and the Director of Plant Operations on the requirements of Fire Safety. A one-time Fire Safety Inspection has been completed to ensure that all Fire Extinguishers have been inspected within the last 12 months. The Director of Outpatient will complete monthly audits to ensure that the Fire Extinguishers are inspected and maintain yearly approval. The Director of Outpatient Services will forward data to the Performance Improvement Committee monthly 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 a completed informed and voluntary consent which included the purpose of the disclosure in one out of seven records reviewed.
Client # 1 was admitted October 1, 2024, and was still active at that the time of the inspection. A release dated October 1, 2024, for a funding source, did not specify the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Performance Improvement will provide education to the Director of Outpatient Services on the requirements of Confidentiality, focusing on completion of consents. Client #1 consent was updated to reflect the purpose of the funding source disclosure. The Director of Outpatient, or designee will provide one to one education to all Outpatient staff members on the requirements of Confidentiality focusing on completion of consents. The Director of Outpatient, or designee will complete an audit of 100% of active patient consents to ensure the purpose of disclosure is specified. The Director of Outpatient will perform monthly audits of consents to ensure the purpose of disclosure is specified. The Director of Outpatient will forward data to the Performance Improvement Committee monthly. |
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of four applicable records reviewed.
Client #2 was admitted on September 17, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was completed on October 14, 2024, and the next update was due no later than December 14, 2024; however, the next update was completed on January 15, 2025.
Client #3 was admitted on September 30, 2024, and was still active at the time of the inspection. A comprehensive treatment plan update was completed on November 11, 2024, and the next update was due no later than January 11, 2025; however, the was no documentation of an updated treatment plan at the time of the inspection.
This is a repeat ciation from the Janaury 24, 2024, licensing renewal inspection.
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 Outpatient on the requirements of treatment plans for all active patients, focusing on treatment plan updates and the required timeframes. The Director of Outpatient Services will provide one to one education to all Outpatient staff members on the requirements of treatment plans for all active patients, focusing treatment plan updates and the required timeframes. The Director of Outpatient, or designee will complete an audit of 100% of active patient treatment plan updates to ensure completion within the required timeframes. The Director of Outpatient will perform monthly audits of active patient charts to ensure treatment plan updates are completed timely. The Director of Outpatient will forward data to the Performance Improvement Committee monthly until continued compliance is sustained. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. 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 client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in five out of seven records reviewed.
Client #1 was admitted on October 1, 2024, and was still active at the time of the inspection. The treatment plan dated October 21, 2024, indicated one group therapy session per week. There was no documentation of the client receiving group therapy between November 3-16, 2024, November 24-30, 2024, and December 15-21, 2024.
Client #2 was admitted on September 17, 2024, and was still active at the time of the inspection. The treatment plan dated October 14, 2024, indicated one group therapy session per week. There was no documentation that the client received group therapy between November 10-15, 2024, November 24-30, 2024, December 15-21, 2024, and December 22-28, 2024.
Client #3 was admitted on September 30, 2024, and was still active at the time of the inspection. The treatment plan dated November 21, 2024, indicated one group therapy session per week. There was no documentation that the client received group therapy between December 15-28, 2024 and December 29, 2024-Janaury 4, 2025.
Client #6 was admitted on March 18, 2024, and was discharged on October 8, 2024.The treatment plan dated March 27, 2024, indicated one individual session per week. There was no documentation that the client received individual therapy between June 30-July 6, 2024 and July 21-27, 2024.
Client #7 was admitted on June 10, 2024, and was discharged on August 8, 2024.The treatment plan dated June 10, 2024, indicated one individual session per week. There was no documentation that the client received individual therapy between June 30-July 6, 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 Outpatient on the requirements of an individual treatment plan for all active patients, focusing on documentation on treatment type. The Director of Outpatient will review and update the treatment plan type for Client #1, Client #2, Client #3, Client #6, and Client #7. The Director of Outpatient Services will provide one to one education to all Outpatient staff members on the requirements of an individual treatment plan for all active patients, focusing on documentation on treatment type. The Director of Outpatient, or designee will complete an audit of 100% of active patient treatment plans to ensure documentation of treatment type. The Director of Outpatient will perform monthly audits of active patient charts to ensure documentation of active patient type is on the treatment plan. The Director of Outpatient will forward data to the Performance Improvement Committee monthly until continued compliance is sustained. |