INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 19, 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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709.33 (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 a review of client records, the facility failed to document a written notice of involuntary termination in one of four client records.
Client #2 was admitted on November 15, 2023 and terminated on December 8, 2023. There was no written termination notice in client record #2.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
The Clinical Supervisor met with the clinical team members on April 15th and reviewed the importance of providing a written notice of involuntary termination in the client record. The Clinical Supervisor will confirm the written notice is present during weekly chart audits for clients who are discharged involuntarily. |
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 unusual incident reports, the facility failed to file a written unusual incident report within 3 business days following an unusual incident involving an event at the facility requiring the presence of ambulance personnel.
An ususual incident occurred on October 7, 2023 in which an ambulance presented to the facility to transport a client for treatment at the emergency room. There was no documentation this this unusual incident report was sent to DDAP.
An ususual incident occurred on October 16, 2023 in which an ambulance presented to the facility to transport a client for treatment at the emergency room. This ususual incident was reported to DDAP on October 26, 2023.
An ususual incident occurred on October 18, 2023 in which an ambulance presented to the facility to transport a client for treatment at the emergency room. This ususual incident was reported to DDAP on October 26, 2023.
An ususual incident occurred on December 15, 2023 in which an ambulance presented to the facility to transport a client for treatment at the emergency room. This ususual incident was reported to DDAP on December 21, 2023.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
The Facility Director met with the Director of Nursing on April 17th to review the policy for reporting unusual incidents and timeframe for reporting to DDAP. The Director of Nursing will confirm the incident report has been submitted by providing the Facility Director with email confirmation for each report sent. The Facility Director will monitor the plan during the weekly departmental meeting. |