Roxbury Treatment Center issued Provisional License because of outdated and missing staff criminal checks and treatment planning violations

The Roxbury Treatment Center Inpatient Unit was cited during a licensure inspection completed by the Pennsylvania Department of Human Services (DHS) for violations of regulations related to staff background checks, adequate treatment, and discharge from voluntary inpatient treatment. DHS revoked the facility’s Certificate of Compliance and issued a 6-month Provisional License and noted “several employee files still did not have appropriate criminal clearances as required by the Child Protective Services Law” and “deficiencies were noted with respect to clinical assessment, treatment planning and delivery and treatment team communication.”

DHS found that 4 personnel records were missing child abuse clearances and 1 record was missing the required FBI clearance. DHS also revealed that 7 personnel records contained late Child Abuse Clearances, 13 record contained late FBI clearances, and 1 record had a late PA State Police clearance. Lastly, DHS found 5 staff records with outdated Child Abuse Clearances and 2 records with outdated FBI clearances.

DHS also found violations of adequate treatment regulations. In one case, staff had documented a suicide attempt by a patient but did not inform the psychiatrist of the attempt. Because the psychiatrist was not notified, he/she documented no self-harming behavior and did not address the suicide attempt with the patient. DHS also found another patient’s medical record that had “major inconsistencies regarding current presence of and past history of self-harming behavior.”

DHS also cited Roxbury Treatment Center for violations of regulations around the discharge from voluntary inpatient treatment. Specifically, DHS found 3 medical records were missing the required discharge summaries. DHS also found that 5 records with involuntary commitment forms with proposed treatment and restrictions that were not completed by the physician until the next day and two records that listed the treatment and restrictions “as per protocol.” Both instances violated regulations on involuntary admission and negated informed consent of the patient.

The facility submitted a plan of correction to address these deficiencies.