INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Davis Archway House 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of client records, the facility failed to ensure staff persons received at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training within the first year in one of one record.
Employee # 3 was hired as a counselor on July 20, 2020. The STD/TB training was due to be completed by July 20, 2021. There was no documentation the training had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will provide the 4hrs of TB/STD training to staff members. The Director of Nursing will complete the training for staff by 10/22/2021. The Clinical Supervisor will monitor for ongoing compliance with the regulation.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on the review of administrative documentation, the facility failed to obtain an annual audit for the fiscal year ending December 31, 2020.
There was no documentation an audit had been completed for the fiscal year ending on December 31, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The audit for 2020 is currently being conducted and will be completed by 11/15/2021. The CEO will ensure the plan of correction is implemented by receiving the final audit from the CPA firm. To ensure the deficiency does not recur, the CEO will schedule the annual meeting with the CPA firm no later than May 1 of each year to begin the audit process. |
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 the review of client records, the facility failed to obtain an informed and voluntary consent from the client in one of seven records.
Client # 4 was admitted on January 29, 2021 and discharged on July 6, 2021. Contact was made with a treatment facility on July 6, 2021. There was no release documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/30/2021, the Clinical Supervisor met with the staff to review the client consent policy and procedures. To ensure compliance, the Clinical Supervisor will be responsible for performing audits each week to review consents within the client records and provide a record of any missing consent forms. The Facility Director will monitor the plan of correction to ensure it has been implemented. |
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 the review of client records, the facility failed to obtain an informed and voluntary consent which included specific information which complies with 4 Pa Code 255.5 (a)(6), in two of seven records.
Client # 2 was admitted on June 14, 2021 and was still an active client at the time of the inspection. A release of information to an employer, signed by the client on August 27, 2021, had specific information to be released that exceeded 4 Pa Code 255.5 (a)(6).
Client # 6 was admitted on April 23, 2021 and discharged on September 13, 2021. A release of information to an employer, signed by the client on April 23, 2021, had specific information to be released that exceeded 4 Pa Code 255.5 (a)(6).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/30/2021, the Clinical Supervisor reviewed all required information to complete a valid consent and to delineate between restricted vs. unrestricted. All staff were instructed on the specific information permitted to be released to employers. To ensure compliance, the Clinical Supervisor will audit client records on a weekly basis. The Facility Director will monitor the plan of correction to ensure it is implemented. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to document the client was notified, in writing, of a decision to involuntarily terminate the client, in one of one record.
Client # 4 was admitted on January 29, 2021 and was involuntarily terminated on July 6, 2021. There was no documentation the client was notified, in writing, of the decision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/30/2021, the Clinical Supervisor met with the clinical team and program assistants to review the policy and procedure for involuntary discharges. All staff were directed to ensure the correct forms were signed by the client prior to discharge. To ensure compliance, the Clinical Supervisor will review all involuntary discharge records to confirm the client was notified in writing of the decision. The Facility Director will monitor the plan to ensure it is implemented. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to document the client was provided the opportunity to request reconsideration of the decision to terminate treatment, in one of one record.
Client # 4 was admitted on January 29, 2021 and was involuntarily terminated on July 6, 2021. There was no documentation the client was provided the opportunity to request reconsideration of the decision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/30/2021, the Clinical Supervisor met with the clinical team and program assistants to review the policy and procedure for involuntary discharges. All staff were directed to ensure the correct forms were signed by the client prior to discharge that indicates the client was provided an opportunity for reconsideration. To ensure compliance, the Clinical Supervisor will review all involuntary discharge records to confirm the client was notified of the opportunity for reconsideration. The Facility Director will monitor the plan to ensure it is implemented. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on the review of client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in five of seven client records.
Client # 3 was admitted on April 12, 2021 and was still an active client at the time of the inspection. Treatment plan updates, due by July 17 and August 17, 2021, were not documented.
Client # 4 was admitted on January 29, 2021 and was discharged on July 6, 2021. A treatment plan update, due by April 22, 2021, was not documented.
Client # 5 was admitted on March 15, 2021 and was discharged on September 13, 2021. A treatment plan update due by May 2, 2021 was completed on May 28, 2021. Treatment plan updates due by June 23 and July 23, 2021 were not documented.
Client # 6 was admitted on April 23, 2021 and was discharged on September 13, 2021. A treatment plan update due by June 5, 2021 was completed on June 25, 2021.
Client # 7 was admitted on January 14, 2021 and was discharged on July 26, 2021. A treatment plan update due by June 13, 2021 was completed on June 24, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
on 9/30/2021, the Clinical Supervisor met with the clinical team to review policies and procedures for treatment plan updates. All staff were trained in the correct procedure for updating treatment plans. To ensure compliance, the Clinical Supervisor will conduct chart audits on a monthly basis to ensure all updates are completed within the 30 day timeframe. The Facility Director will monitor the plan to ensure it has been implemented. |