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Based on review of facility documents, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure patients had a history and physical completed within 24 hours after admission in five of ten medical records reviewed (MR2, MR4, MR5, MR8, and MR9).

Findings include:

A review on June 2, 2011, of Roxbury Treatment Center Policy: Assessment and Reassessment, last reviewed by the facility in July 2010, revealed, "All patients admitted to Roxbury receive a thorough and timely assessment and evaluation .... D. History and Physical 1. The physician or appropriately qualified designee will complete a medical history and physical evaluation within 24 hours of admission ...."

A review of medical records conducted on June 1 and 2, 2011, revealed that all patients had been admitted May 31, 2011 or earlier, and that MR2, MR4, MR5, MR8, and MR9, did not contain documentation that a history and physical examination were performed within the first 24 hours after the patients' admission.

An interview conducted on June 1, 2011, at 3:00 PM with EMP4 confirmed that MR2 and MR4 did not contain documentation that a history and physical examination were performed within the first 24 hours after the patients' admission.

An interview conducted on June 2, 2011, at 10:00 AM with EMP2 confirmed that MR5, MR8 and MR9 did not contain documentation that a history and physical examination were performed within the first 24 hours after the patients' admission.

Based on review of facility documentation, review of medical record (MR), and staff interview (EMP), it was determined that the facility failed to keep a current treatment plan and failed to include medically diagnosed conditions with ongoing treatments for six of ten medical records reviewed (MR1, MR2, MR5, MR6, MR9, and MR10).

Findings include:

A review on June 2, 2011, of Roxbury Treatment Center Policy: Treatment Care Planning-Inpatient, last reviewed by the facility in July 2010, revealed, " The Roxbury Treatment Center will provide an intentional course of treatment based on the needs and circumstances of the patient through the implementation of an individual treatment plan that will be developed with each patient. The plan will be based on information derived from the multi-disciplinary Intake assessment process and the Psychosocial Evaluation .... II. Treatment Care Plan An individual Treatment Care Plan shall be developed within 72 hrs of admission with participation from the patient, and family ' s input when available and appropriate ....III Treatment Care Plan Updates An individual Treatment Care Plan shall be reviewed and updated on a weekly basis or with change in patient condition by the treatment team .... "

1) Review on June 1, 2011 of MR1, for a current inpatient, revealed a diagnosis of " NIDDM " (non-insulin dependent diabetes mellitus) and doctor ' s order for a diabetic medication, Metformin, a diabetic diet and blood sugar testing, dated April 6, 2011. Review of the Treatment Plan for MR1 revealed it did not contain information regarding the patient ' s diabetic condition.

Review on June 1, 2011 of MR2, for a current inpatient, revealed diagnoses of " migraine " and " NIDDM " (non-insulin dependent diabetes mellitus) and doctor ' s order for a migraine medication, Imitrex, a diabetic medication, Metformin, a diabetic diet and blood sugar testing, dated May 20, 2011. Review of the Treatment Plan for MR2 revealed it did not contain information regarding the patient ' s migraine condition or diabetic condition.

An interview conducted on June 1, 2011, at 3:00 PM with EMP4 confirmed that MR1 and MR2 contained documentation of medical conditions and treatments that were not included in the treatment care plan.

2) Review on June 2, 2011 of MR5, for a current inpatient, revealed a diagnosis of " COPD " (Chronic Obstructive Lung Disease) and doctor ' s order for two inhaled medications to treat breathing problems, dated May 25, 2011. Review of the Treatment Plan for MR5 revealed it did not contain information regarding the patient ' s COPD condition.

Review on June 2, 2011 of MR9, for a current inpatient, revealed a diagnosis of " URI " (Upper Respiratory Infection) and extreme underweight with nutritional deficit. Review of the Treatment Plan for MR9 revealed it did not contain information regarding the patient ' s URI or extreme underweight condition.

An interview conducted on June 2, 2011, at 10:00 AM with EMP2 confirmed that MR5 and MR9 contained documentation of ongoing medical conditions and treatments that were not included in the treatment care plan.

3) Review on June 2, 2011 of MR6, for a current inpatient, revealed a Treatment Plan that contained a reference of " Pain " , but failed to describe the pain by location or intensity, or prescribed treatment.

An interview conducted on June 2, 2011, at 10:00 AM with EMP2 confirmed that MR6 contained treatment care plan that included " pain " as a problem without describing either the nature of the pain or any treatment ordered.

4) Review on June 2, 2011 of MR10, for a current inpatient, revealed a Treatment Plan that was last updated on May 20, 2011.

An interview conducted on June 2, 2011, at 10:00 AM with EMP2 confirmed that MR10 contained a treatment plan that had not been updated on a weekly basis.