INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted August 9-10, 2023, 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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709.52(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 a review of client charts on August 9-10, 2023, the facility failed to ensure that treatment and rehabilitation plans are reviewed every 15 days in three of seven client records.
Client #4 was admitted to detoxification services on 5/9/23 and stepped down to residential rehabilitation services on 5/16/23 and was discharged on 7/20/23. The treatment plan updates were missing from the chart.
Client #5 was admitted to rehabilitation services on 4/20/23 and discharged on 6/8/23. The treatment plan updates were missing from the chart.
Client #7 was admitted to rehabilitation services on 4/28/23 and was discharged on 8/2/23. The treatment plan updates were missing from the chart.
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Plan of Correction
The counselor that was responsible for two of the three charts was terminated prior to this visit for failure to maintain proper documentation in the client record. The Clinical Supervisor reviewed the correct timeframes for treatment plan updates with the clinical team. The Clinical Supervisor will audit one chart per week for each team member and will confirm treatment plan updates are documented. The POC will be monitored by the Executive Director to ensure compliance. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client charts on August 9-10, 2023, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in two of seven client records.
Client #1 was admitted to detoxification services on 5/3/23, stepped down to rehabilitation services on 5/10/23, and was a current client at the time of the investigation. The master treatment plan dated 5/23/23 indicates weekly individual sessions to occur. There is no documentation of individual sessions occurring during the weeks of June 20th and June 27th.
Client #3 was admitted to detoxification services on 4/19/23, stepped down to rehabilitation services on 4/26/23 and was discharged on 7/19/23. The treatment plan updated on 7/7/23 indicates weekly individual sessions to occur. There is no documentation of an individual session during the week of July 12th.
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Plan of Correction
The Clinical Supervisor met with the clinical team and reminded them of the required documentation for individual sessions. The Clinical Supervisor will conduct chart audits each week on Wednesday and Thursday for each team member to confirm session notes are present. The Executive Director will monitor the plan of correction to ensure compliance. |
709.53(a)(6) LICENSURE Ind. Tx. Plan
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:
(6) Individualized treatment and rehabilitation plan.
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Observations
Based on a review of client charts on August 9-10, 2023, the facility failed to ensure a complete client record in five of seven client records.
The facility's Inpatient Intake and Admission policy indicates that within seven days of admission, the individualized treatment and rehabilitation plan will be completed.
Client #1 was admitted to detoxification services on 5/3/23, stepped down to rehabilitation services on 5/10/23, and was a current client at the time of the investigation. The master treatment plan was completed on 5/23/23 and it should have been completed by 5/17/23.
Client #4 was admitted to detoxification services on 5/9/23 and stepped down to residential rehabilitation services on 5/16/23 and was discharged on 7/20/23. The treatment plan was completed on 5/31/23 and should have been completed by 5/23/23.
Client #5 was admitted to rehabilitation services on 4/20/23 and discharged on 6/8/23. The initial treatment plan was completed 4/20/23. The master treatment plan was completed on 5/4/23 and it should have been completed by 4/27/23.
Client #6 was admitted for rehabilitative services on 7/7/23 and discharged on 7/21/23. The initial treatment plan was dated 7/8/23. The master treatment plan should have been completed by 7/15/23. There was no master treatment plan.
Client #7 was admitted to rehabilitation services on 4/28/23 and was discharged on 8/2/23. The initial treatment plan was completed on 5/5/23. The master treatment plan was completed on 5/16/23 and it should have been completed by 5/12/23.
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Plan of Correction
The Clinical Supervisor met with the clinical team and reviewed the timeframes for documentation of the treatment plan. The Clinical Supervisor will review charts as clients are admitted to ensure the counselor is completing the treatment plan within 7 days of admission. The Executive Director will monitor the plan of correction to ensure compliance. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client charts on August 9-10, 2023, the facility failed to ensure a complete client record to include a discharge summary in one of seven client records.
Client #3 was admitted to detoxification services on 4/19/23, stepped down to rehabilitation services on 4/26/23 and was discharged on 7/19/23. The client chart was missing a discharge summary. The discharge note dated 7/20/23 was blank.
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Plan of Correction
During weekly chart audits, the Clinical Supervisor will review charts for clients who have discharged from the facility. The Clinical Supervisor will ensure the discharge summary and discharge note are completed for all clients. The Executive Director will monitor the plan of correction for compliance. |