INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19, 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 House 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of staff records, the facility failed to document that each staff member providing clinical services met the qualifications of counselor in one of two records.Staff #5 was hired as a counselor on January 16, 2023. During the review of the staff record, it was determined that Staff #5 has eight months of clinical experience. The Department requires one year of experience for a counselor with an accepted Bachelor ' s degree. This was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor updated the employee position from Counselor to Counselor Assistant. The Clinical Supervisor will provide the required supervision and will look to transition the employee back to Counselor once the qualifications are met. For future hires in the clinical team, the facility will require final approval by the Clinical Supervisor who will review the resume and determine if qualifications have been satisfied. The POC will be monitored by the Clinical Supervisor 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 #3 was admitted on June 23, 2023 and was discharged on July 12, 2023. No treatment plans in the record included proposed types of supportive services.Client #5 was admitted on June 19, 2023 and was still active at the time of the inspection. No treatment plans in the record included proposed types of supportive services.Client #6 was admitted on August 24, 2023 and was still active at the time of the inspection. No treatment plans in the record included proposed types of supportive services.Client #7 was admitted 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
After the licensing visit, the Clinical Supervisor met with each clinical team member to review the correct documentation requirements. Each team member was made aware of the need for support services to be documented in the treatment plan. During weekly chart audits, the Clinical Supervisor will ensure support services are listed 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 four of four applicable records.Client #1 was admitted on February 9, 2023 and was discharged on May 29, 2023. A treatment and rehabilitation plan was developed on February 17, 2023. A treatment and rehabilitation plan update was due no later than March 17, 2023, but was not completed until March 21, 2023.A treatment and rehabilitation plan was developed on April 18, 2023. A treatment and rehabilitation plan update was due no later than May 18, 2023, but was not completed at the time of the inspection.Client #2 was admitted on April 6, 2023 and was discharged on June 9, 2023. A treatment and rehabilitation plan was developed on April 7, 2023. A treatment and rehabilitation plan update was due no later than May 7, 2023, but was not completed until June 6, 2023.Client #4 was admitted on March 30, 2023 and was discharged on July 18, 2023. A treatment and rehabilitation plan was developed on April 11, 2023. A treatment and rehabilitation plan update was due no later than May 11, 2023, but was not completed until June 14, 2023.Client #5 was admitted on June 19, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 29, 2023. A treatment and rehabilitation plan update was due no later than July 29, 2023, but was not completed until August 14, 2023.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 20, 2022 and September 16, 2021 annual licensing inspections.
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Plan of Correction
The Clinical Supervisor met with the clinical team and reviewed the required timeframes for treatment plan updates. During weekly chart audits the Clinical Supervisor will review documentation to ensure the treatment plan is updated within the 30 day timeframe. |
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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in three of seven applicable records. The facility policy and procedure manual indicate a case consultation to occur within fifteen days of intake, then every thirty days after. Client #2 was admitted on April 6, 2023 and was discharged on June 9, 2023. A case consultation was due to occur no later than June 4, 2023, but was not completed at the time of the inspection.Client #4 was admitted on March 30, 2023 and was discharged on July 18, 2023. A case consultation was due to occur no later than May 6, 2023, but was not completed until June 14, 2023.Client #5 was admitted on June 19, 2023 and was still active at the time of the inspection. A case consultation was due to occur no later than July 26, 2023, but was not completed until September 14, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the deficiency, the Clinical Supervisor will review current charts to make sure all consultations are up to date. Also, during the morning clinical team meeting, the staff will review consultations twice each week. The Clinical Supervisor will keep track of due dates and will send reminders to staff. The Clinical Supervisor will monitor the plan to ensure compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for treatment plan update was submitted and approved by the Department for the October 20, 2022 and September 16, 2021 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the September 19, 2023 annual licensing inspection.This was reviewed with the facility staff during the licensing process.
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Plan of Correction
To address the deficiency, the Clinical Supervisor will review current charts to ensure they are updated. The clinical team will review treatment plan updates during case consultations twice per week. The Clinical Supervisor will review updates during weekly chart audits, and will monitor the plan to ensure compliance. |