INITIAL COMMENTS
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This report is a result of on-site complaint investigations on September 18, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Davis Archway Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records and unusual incident reports, the facility failed to file a written unusual incident report with the Department within 3 buisness days following an event at the facility requiring the presence of ambulance personnel.
Client #1 was admitted to the detox level of care on September 6, 2024 and discharged on September 13, 2024. On September 12, 2024, client #1 was taken from the facility to the emergency room via ambulance. There was no documentation that an unusual incident report was filed with DDAP within 3 business days.
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Plan of Correction
The Facility Director reviewed the unusual incident reporting policy with the Director of Nursing and the nursing staff on October 11, 2024. Staff have been made aware or the reporting timeframes and will be responsible for submissions when the Director of Nursing is not on site. This plan will be monitored by the Facility Director for compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultation notes as per facility policy in five of five client records. Per the facility policy, case consultations are to occur within the first 7 days of admission and then every 15 days thereafter.
Client #1 was admitted to residential treatment on July 18, 2024 and is currently active in treatment. There were no case consultations documented in client record #1.
Client #2 was admitted to residential treatment on August 27, 2024 and is currently active in treatment. There were no case consultations documented in client record #2.
Client #3 was admitted to residential treatment on July 13, 2024 and is currently active in treatment. One case consultation was documented on July 27, 2024. There was no additional case consultations documented in client record #3.
Client #4 was admitted to residential treatment on August 9, 2024 and is currently active in treatment. One case consultation was documented on August 29, 2024. There was no additional case consultations documented in client record #4.
Client #5 was admitted to residential treatment on September 9, 2024 and is currently active in treatment. There were no case consultations documented in client record #5.
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Plan of Correction
On October 4, 2025, the Facility Director met with the clinical team members to review the policy for case consultations and timeframe for documentation. All staff were made aware of the deficiencies and were informed of the expectation for getting documentation into the client chart. The Facility Director will monitor the case consultation documentation in the new electronic record to ensure they are completed in a timely manner. This plan shall be monitored on a weekly basis to ensure compliance. |