INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 10, 2023 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 three 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,and 6.
Client # 1 was admitted on August 23, 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 the funding source and lab prior to the release of information to these agencies. Authorizations for funding source was documented in the client record on January 9, 2023. Correspondence with a lab on November 22, 2022.
Client # 6 was admitted on March 8, 2022 and was discharged on April 18, 2022. There was no documentation of an informed and voluntary consent from the client for the disclosure of information to the funding source until April 8, 2022. Correspondences with the funding source were documented on April 1, 2022 and April 6, 2022.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from the January 18, 2022 licensing inspection.
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Plan of Correction
The Director of Outpatient Services will be responsible for the overall oversight of audits as well as peer audits will occur to ensure adherence to a particular form to be completed that will track and initiate the Staff member completing the consents to do so correctly. This was addressed immediately after the date of the inspection with re-training of the entire department both in a group supervision as well as one on one. Facility to be in full compliance with the standard immediately. |
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 #4 was admitted on November 2, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated November 22, 2022 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.
This is a repeat citation from the January 18, 2022 licensing inspection
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Plan of Correction
The Director of Outpatient Services will be responsible for the overall oversight of audits as well as peer audits will occur to ensure adherence to a particular form to be completed that will track and initiate the Staff member completing the consents to do so correctly. This was addressed immediately after the date of the inspection with re-training of the entire department both in a group supervision as well as one on one. Facility to be in full compliance with the standard immediately. |
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 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 purpose of the disclosure.
Client #2 was admitted on November 16, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated November 16, 2022 to an emergency contact did not provide the purpose of the disclosure.
Client # 6 was admitted on March 8, 2022 and was discharged on April 18, 2022. An informed and voluntary consent from the client for the disclosure of information dated March 18, 2022 to an emergency contact and physician did not provide the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 18, 2022 licensing inspection.
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Plan of Correction
The Director of Outpatient Services will be responsible for the overall oversight of audits as well as peer audits will occur to ensure adherence to a particular form to be completed that will track and initiate the Staff member completing the consents to do so correctly. This was addressed immediately after the date of the inspection with re-training of the entire department both in a group supervision as well as one on one. Facility to be in full compliance with the standard immediately. |