INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20, 2023 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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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 client records reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in one of two applicable records.
Client #11 was admitted to inpatient on January 19, 2023 and discharged on March 20, 2023. There was no documentation in the client record notifying the client in writing of termination from the project.
This is a repeat citation from the October 19, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The discharge form has been updated to include a section to notify the client of termination from the program. All staff were notified at the daily clinical team meeting. The CEO will monitor the POC to ensure compliance. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed types of supportive services in the individual treatment plan in four of seven client records.
Client #10 was admitted to inpatient on April 4, 2023 and was discharged on June 13, 2023. No treatment plans in the record included proposed types of supportive services.
Client #12 was admitted to inpatient on July 10, 2023 and was still active at the time of the inspection. No treatment plans in the record included proposed types of supportive services.
Client #13 was admitted to inpatient on July 26, 2023 and was still active at the time of the inspection. No treatment plans in the record included proposed types of supportive services.
Client #14 was admitted to inpatient on August 10, 2023 and was still active at the time of the inspection. No treatment plans in the record included proposed types of supportive services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and CEO met with the clinical team and they were reminded of correct documentation for treatment plans. The Clinical Supervisor will monitor the POC by completing weekly chart audits to ensure compliance. |
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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in two of five applicable records.
Client #12 was admitted to inpatient on July 10, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on July 19, 2023. A treatment and rehabilitation plan update was due no later than August 19, 2023, but was not completed until August 23, 2023.
Client #13 was admitted to inpatient on July 26, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 1, 2023. A treatment and rehabilitation plan update was due no later than September 1, 2023, but was not completed until September 7, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and CEO met with the clinical team and reminded them of the timeframe for reviewing and updating the treatment plan. The Clinical Supervisor will monitor the POC during weekly chart audits to ensure compliance. |