INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 10 - 12, 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 Treatment Center 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The facility video camera system is located within the counseling areas.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director contacted the company that installed the video/camera system after facility was built. This company is scheduled to move the cameras into "common areas", in the hallways, and outside of all offices so that they can be used for security purposes, which was the systems original purpose.
The Facility director will make sure this job is completed by monitoring job progress once a week until all cameras are moved and the job is complete. The company anticipated the job would take 1 to 2 days to complete. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on the physical plant inspection, the facility failed to document inspections of the medication areas per the facility policy and procedure. The facility was given approval to begin services in March 2020. The facility has three medication carts located in detoxification, residential female, and residential male units.
The policy and procedure for the residential treatment activity states quarterly inspections will be conducted. Quarterly inspections were not documented for April - June 2020 and July - September 2020.
The policy and procedure for the detox activity states monthly inspections will be conducted. Monthly inspections were not documented for April, May, June, July, August, September, October and December 2020, and January 2021.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Nurse manager will meet with all current nurses for a review and new nurses at the time of hirer, to provide education on the facility's policy and procedure for medication area inspections and related documentation. All nurses will attest that they understand the facility's policy and procedure including the documentation of the inspections for the Residential program on a Quarterly basis and for Detox on a Monthly basis.
The Nurse Manager will be responsible to conduct and document medication area inspections on the above time frames for each program.
The Facility director on a quarterly basis will review the documentation of the medication area inspections ensuring they are being conducted and documented within the appropriate time frames on a by the Nurse manager for each program. |
715.6(a)(3)(ii) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(3) The medical director 's responsibilities include the following:
(ii) Supervision of licensed practical nurses if the narcotic treatment program does not employ a registered nurse to supervise the nursing staff. In addition, the medical director in these instances shall ensure that licensed practical nurses adhere to written protocols for dispensing and administration of medication.
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Observations
Based on a review of administrative information, the facility failed to document the medical director ' s responsibilities include the supervision of licensed practical nurses on staff. In addition, the medical director shall ensure that licensed practical nurses adhere to written protocols for dispensing and administration of medication.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
The HR Manager will include the following in the job description and signed agreement form the following duties added that any new hires for this position will sign and the current Medical director will sign.
The following will be added to the job description of the Medical Director position: Medical director's responsibilities include the supervision of licensed practical nurses on staff. In addition, the medical director shall ensure that licensed practical nurses adhere to written protocols for dispensing and administration of medication.
Medical director will document supervision in a log with date, time, and content.
Nurse manager will provide training for all nurses on protocols for dispensing and administration of medication, keeping a log of such education and training. |
715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
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Observations
Based on a review of administrative information, the facility failed to document a narcotic treatment physician ' s responsibilities include (1) Performing a medical history and physical exam, (2) Determining diagnosis and determining narcotic dependence, (3) Reviewing treatment plans, (4) Determining dosage and all changes in doses, (5) Ordering take-home privileges, (6) Discussing cases with the treatment team, (7) Issuing verbal orders pertaining to patient care, (8) Assessing coexisting medical and psychiatric disorders, and (9) Treating or making appropriate referrals for treatment of these disorders.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will write all Davis Archway policies and procedures as relates to Chapter 715 of the Dept of Drug and Alcohol licensing. The Clinical Director will then monitor each regulation according to each individual regulation's method and time frame for monitoring within Chapter 715.
In addition, the HR Manager will add to the Medical Director job description and signed agreement form the following:
(1) Performing a medical history and physical exam, (2) Determining diagnosis and determining narcotic dependence, (3) Reviewing treatment plans, (4) Determining dosage and all changes in doses, (5) Ordering take-home privileges, (6) Discussing cases with the treatment team, (7) Issuing verbal orders pertaining to patient care, (8) Assessing coexisting medical and psychiatric disorders, and (9) Treating or making appropriate referrals for treatment of these disorders.
The HR Manager will have any new hires for this Medical Director position sign this updated job description and agreement form. The HR manager will have the current Medical Director sign this updated job description and agreement form. |
715.9(d) LICENSURE Intake
(d) A narcotic treatment program shall explain to each patient treatment options; pharmacology of methadone, LAAM and other agents, including signs and symptoms of overdose and when to seek emergency assistance; detoxification rights; grievance procedures; and clinic charges, including the fee agreement signed by the patient.
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Observations
Based on a review of patient records, the facility failed to document they explain to each patient the treatment options; pharmacology of methadone, LAAM and other agents, including signs and symptoms of overdose and when to seek emergency assistance; detoxification rights; grievance procedures; and clinic charges, including the fee agreement signed by the patient in three of three buprenorphine patient records reviewed.
Patient #3 was admitted to detox treatment on November 29, 2020 and discharged on December 5, 2020. First dose of buprenorphine was on November 30, 2020 and did not have documentation.
Patient #8 was admitted to detox treatment on January 19, 2021, was transferred to residential treatment on January 26, 2021. First dose of buprenorphine was on January 19, 2021 and did not have documentation.
Patient #10 was admitted to detox treatment on January 27, 2021, was discharged on February 3, 2021. First dose of buprenorphine was on January 27, 2021 and did not have documentation.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Nurse Manage will develop a form that explains to each patient the treatment options; pharmacology of methadone, LAAM and other agents, including signs and symptoms of overdose and when to seek emergency assistance; detoxification rights; grievance procedures; and clinic charges including the fee agreement.
The nursing staff will have patients, during the admission process to 3.7 LOC, sign this form. Patient signature verifies that this information was presented.
The Nurse Manager will monitor that this correction has been done through monthly chart audits of 3.7 patients. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of patient records, the facility failed to ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
One of the three buprenorphine patient records reviewed was a female. Patient #3 was a female admitted to detox treatment on November 29, 2020 and discharged on December 5, 2020. First dose of buprenorphine was on November 30, 2020. There was no documentation Patient #3 was informed of the risks.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
Nurse Manager will develop a form that notifies and informs all female patients of the possible risks to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
The nursing staff will have all female patients sign this form during the admission process to 3.7 LOC.
The Nurse manager will monitor that this correction has been made by monthly chart audit of all female patients in 3.7. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to document an informed patient consent prior to the use of buprenorphine in three of three buprenorphine patient records reviewed. The buprenorphine consent used by the facility does not include:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
Patient #3 was admitted to detox treatment on November 29, 2020 and discharged on December 5, 2020. First dose of buprenorphine was on November 30, 2020.
Patient #8 was admitted to detox treatment on January 19, 2021, was transferred to residential treatment on January 26, 2021. First dose of buprenorphine was on January 19, 2021.
Patient #10 was admitted to detox treatment on January 27, 2021, was discharged on February 3, 2021. First dose of buprenorphine was on January 27, 2021.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Nurse Manager will add the following into the existing Buphenorphine Informed Consent Form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
Nursing staff will have the patient sign this updated informed consent form prior to starting Buphenorphine within the 3.7 program. The nursing staff will have any 3.7 patients currently receiving Buphenorphine sign the updated form with date.
The Nurse Manager will review 3.7 patient records each month to ensure this is being followed.
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715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
Based on a review of administrative information, the facility failed to develop and implement policies and procedures to ensure that urine collected from patients is unadulterated, and includes random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will write all Davis Archway policies and procedures as relates to Chapter 715 of the Dept of Drug and Alcohol licensing. The Clinical Director will then monitor each regulation according to each individual regulation's method and time frame for monitoring within Chapter 715.
Specifically, this policy and procedure will ensure that urine collected from patients is unadulterated, and includes random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
The policy and procedure will in accordance with SAMSHA's Urine Specimen Collection Handbook. |
715.14(c) LICENSURE Urine testing
(c) A narcotic treatment program shall develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
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Observations
Based on a review of administrative information, the facility failed to develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will write all Davis Archway policies and procedures as relates to Chapter 715 of the Dept of Drug and Alcohol licensing. The Clinical Director will then monitor each regulation according to each individual regulation's method and time frame for monitoring within Chapter 715.
More specifically, the policy will ensure procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor. The policy will reflect current guidelines from SAMSHA's Urine Collection Handbook. |
715.14(d) LICENSURE Urine testing
(d) A narcotic treatment program shall ensure that a laboratory that performs the testing required under this section shall be in compliance with applicable Federal requirements, specifically the Clinical Laboratory Improvement Amendments of 1998 (42 U.S.C.A. §§ 201 note, 263 and 263a notes), and State requirements, specifically the Pennsylvania Clinical Laboratory Act (35 P.S. §§ 2151-2165) and Chapter 5 (relating to clinical laboratories).
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Observations
Based on a review of administrative information, the facility failed to ensure the laboratory that performs the testing required under this section shall be in compliance with applicable Federal requirements, specifically the Clinical Laboratory Improvement Amendments of 1998 (42 U.S.C.A. 201 note, 263 and 263a notes), and State requirements, specifically the Pennsylvania Clinical Laboratory Act (35 P.S. 2151-2165) and Chapter 5 (relating to clinical laboratories).
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will call by telephone and contact by email the contact person at the utilized laboratory by 3/15/2021 and request a copy of the needed certificates.
The Facility director will obtain the required laboratory certificates as soon as possible to ensure the certificates will be available for future inspections. |
715.15(f) LICENSURE Medication dosage
(f) The narcotic treatment program shall develop written policies and procedures relating to narcotic treatment medication dosage which includes the requirements of subsections (a)--(e).
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Observations
Based on a review of administrative information, the facility failed to develop written policies and procedures relating to narcotic treatment medication dosage which includes the requirements of subsections (b).
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will write all Davis Archway policies and procedures as relates to Chapter 715 of the Dept of Drug and Alcohol licensing. The Clinical Director will then monitor each regulation according to each individual regulation's method and time frame for monitoring within Chapter 715.
More specifically, the policy and procedures will be written to ensure the requirements of subsection (b) are met, in that, the narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient's initial dose and schedule. |
715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
Based on a review of administrative information, the facility failed to develop and implement policies and procedures regarding involuntary terminations.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will develop and implement clinical policy and procedures for the involuntary termination of a patient's treatment.
More specifically, the policy and procedure will include the following from § 715.21
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
The Facility Director will ensure this policy and procedure is completed by the Clinical Director by 3/15/2021. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on a review of administrative information, the facility failed to develop a patient grievance procedure.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will write all Davis Archway policies and procedures as relates to Chapter 715 of the Dept of Drug and Alcohol licensing. The Clinical Director will then monitor each regulation according to each individual regulation's method and time frame for monitoring within Chapter 715.
More specifically, the policy and procedure will outline the following Davis Archway Policy and Procedures. It is in the patient handbook but also patient the Bill of Rights and Patient Grievance policy will be included in the Informed Consent Form and signed by the patient upon admission.
The policy will be written to meet these procedures outlined in § 715.22. Patient grievance procedures.
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
The grievance policy and procedure will be completed by 3/15/2021 and the Facility director will ensure the Clinical director completes this correction.
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715.26(b) LICENSURE Security
(b) Each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison.
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Observations
Based on a review of administrative information, the facility failed to develop a specific plan describing the efforts it will make to avoid disruption of the community by its patients, the actions it will take to assure responsiveness to the community, and designate a staff member to act as community liaison.
The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The following will policy and procedure will describe a plan to minimize or avoid disruption
§ 715.26. Security.
(b) Each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison.
The Clinical Director will be responsible to develop this plan by 3/15/2021. The community liason will be the Clinical director or the clinical supervisor if the Clinical director is unavailable.
The Facility director will ensure the plan is developed and added to the Policy and Procedures Manual for Chap 715 by the Clinical director by 3/15/2021.
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715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on a review of administrative information, the facility failed to develop and implement policies and procedures to respond to the following unusual incidents:
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents that narcotic treatment program believes should be documented.
The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Clinical Director will write all Davis Archway policies and procedures as relates to Chapter 715 of the Dept of Drug and Alcohol licensing. The Clinical Director will then monitor each regulation according to each individual regulation's method and time frame for monitoring within Chapter 715.
More specifically, the Clinical director will develop and implement a policy and procedure by 3/15/2021 that respond to the following unusual incidents:
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents that narcotic treatment program believes should be documented.
The findings have been reviewed with the facility staff during the inspection.
The Facility director will ensure this policy and procedure is completed by the Clinical director by 3/15/2021.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to include type and frequency of treatment and rehabilitation services on the treatment plan in three of six applicable records reviewed for the residential treatment activity.
Client #1 was admitted to treatment on August 10, 2020 and was discharged on September 8, 2020. Treatment plans were completed on August 17, 2020 and September 1, 2020 and neither included the type and frequency of treatment services.
Client #2 was admitted to treatment on October 30, 2020 and was discharged on November 30, 2020. Treatment plan completed on November 5, 2020 did not include the type and frequency of treatment services.
Client #5 was admitted to treatment on January 6, 2021 and was discharged on February 4, 2021. Treatment plan completed on January 8, 2021 did not include the type and frequency of treatment services.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will update the Initial Treatment Plan, the Individual Treatment Plans, and the Treatment Plan review and all related objectives/interventions within the EMR to reflect current Davis Archway clinical policies and procedures and/or applicable DDAP regulations when appropriate.
The Clinical director will complete a clinical staff training that addresses the EMR update and provide education for the counselors on regulations regarding these clinical documents. By April 1st, 2021 the training will be completed.
The Clinical director will then on a monthly basis monitor via chart audit that this correction is being followed the counselors at the facility. |
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 records, the facility failed to review and update treatment plans per the policy in two of six applicable client records reviewed for the residential treatment activity.
The facility policy states reviews will occur within fifteen days of admission and then every thirty days.
Client #2 was admitted to treatment on October 30, 2020 and was discharged on November 30, 2020. Treatment plans were completed on November 1 and 5, 2020. There was no documentation of a treatment plan review.
Client #7 was admitted to treatment on January 11, 2021 and was still a client at the time of the inspection. Treatment plans were completed on January 11 and 12, 2021. There was no documentation of a treatment plan review.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will update the Initial Treatment Plan, the Individual Treatment Plans, and the Treatment Plan review and all related objectives/interventions within the EMR to reflect current Davis Archway clinical policies and procedures and/or applicable DDAP regulations when appropriate.
Clinical Director will update the Initial Treatment Plan, the Individual Treatment Plans, and the Treatment Plan review and all related objectives/interventions within the EMR to reflect current Davis Archway clinical policies and procedures and/or applicable DDAP regulations when appropriate.
The Clinical director will complete a clinical staff training that addresses the EMR update and provide education for the counselors on regulations regarding these clinical documents. By 04/01/2021, the Clinical director will complete the counselor training and education.
The Clinical director will then on a monthly basis monitor via chart audit that this correction is being followed the counselors at the facility. |
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 records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in two of six applicable client records reviewed for the residential treatment activity.
Client #6 was admitted to treatment on December 14, 2020 and was still a client at the time of the inspection. A treatment plan was completed on December 14, 2020 and indicated two individual sessions per week. For the weeks of December 20, 27, January 3, 10, and 17 only one individual session was documented.
Client #7 was admitted to treatment on January 11, 2021 and was still a client at the time of the inspection. A treatment plan was completed on January 11, 2021and indicated two individual sessions per week. For the weeks of January 24, and 31 only one individual session was documented.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will update the Initial Treatment Plan, the Individual Treatment Plans, and the Treatment Plan review and all related objectives/interventions within the EMR to reflect current Davis Archway clinical policies and procedures and/or applicable DDAP regulations when appropriate.
The Clinical director will complete a clinical staff training that addresses the EMR update and provide education for the counselors on regulations regarding these clinical documents. By 04/01/2021, the Clinical director will have a date and time to provide this counselor training and education.
The Clinical director will then on a monthly basis monitor via chart audit that this correction is being followed the counselors at the facility. |
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 in two of six applicable client records reviewed for the residential treatment activity.
The facility policy states case consultations will be completed within seven days of admission and then every thirty days.
Client #2 was admitted to treatment on October 30, 2020 and was discharged on November 30, 2020. There was no documentation of a case consultation note.
Client #7 was admitted to treatment on January 11, 2021 and was still a client at the time of the inspection. There was no documentation of a case consultation note.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will update the Initial Treatment Plan, the Individual Treatment Plans, and the Treatment Plan review and all related objectives/interventions within the EMR to reflect current Davis Archway clinical policies and procedures and/or applicable DDAP regulations when appropriate.
The Clinical director will complete a clinical staff training that addresses the EMR update and provide education for the counselors on regulations regarding these clinical documents. By 04/01/2021, the Clinical director will complete the counselor training and education.
The Clinical director will then on a monthly basis monitor via chart audit that this correction is being followed the counselors at the facility. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records and discussions with the director, the facility failed to document verification that any work done by the client at the project is an integral part of the treatment and rehabilitation plan in all residential client records reviewed.
These findings have been reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will develop and implement policy and procedures that establish Activities of Daily Living into the general programming.
A training date has been scheduled for 3/24/2021 for the clinical staff training regarding documentation to verify work done by clients is part of the treatment and rehabilitation plan. The training will be conducted by the Clinical Director.
The Clinical Director will monitor via monthly chart audit to verify the correct documentation is in place. |