INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 20, 2022 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of policy and procedures, the facility failed to document a complete written procedure for the management of treatment/rehabilitation services for clients.
There was no documentation of policy and procedure for notifying emergency contacts when an individual leaves treatment against medical advice to comply with Act 41 of 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Davis Archway wrote a policy for all staff to comply with the reporting requirements of Act 41 of 2021. Adherence to this requirement will be monitored by the Director during weekly chart audits. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documentation, the facility failed to document an annual financial audit for the year ending December 31, 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 16, 2021 annual licensing inspection.
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Plan of Correction
The 2021 Audit was completed in November 2022. The 2022 Audit will be completed on schedule. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records.
Client #1 was admitted on February 11, 2022 and discharged on May 25, 2022. There was no client consent documented for the funding source in client record #1.
The licensing specialist confirmed with facility staff that services were billed and funds received for client #1.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 16, 2021 annual licensing inspection.
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Plan of Correction
The Director met with the clinical team to review requirements of consent forms. Reviewed the types of consent forms and their correct application. This plan will be monitored by the Director during weekly chart audits. |
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 notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project in two of two residential client records.
Client #2 was admitted on April 22, 2022 and involuntarily discharged from residential treatment on July 2, 2022. There was no documentation of written notification of termination in client record #2.
Client #4 was admitted on July 20, 2022 and involuntarily discharged from residential treatment on September 27, 2022. There was no documentation of written notification of termination in client record #4.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 16, 2021 annual licensing inspection.
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Plan of Correction
All staff conducting discharges were trained to complete the ASR/Involuntary Discharge Notification prior to client discharge. The form will be signed by staff and client. Compliance with this plan will be monitored by the Director during weekly chart audits. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a physical examination in three of seven client records.
Client #1 was admitted on February 11, 2022 and discharged on May 25, 2022. There was no physical examination documented in client record #1.
Client # 2 was admitted on April 12, 2022 and discharged on July 2, 2022. There was no physical examination documented in client record #2.
Client #6 was admitted on August 2, 2022 and is currently an active client. There was no physical examination documented in client record #6.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Medical Director met with the Director and Physicians to review the scheduling of clients for physical exam. All staff were reminded of the requirement in getting the exam scheduled on time. This plan will be monitored by the Director of Nursing for 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 a review of client records, the facility failed to document a treatment plan update at least every 30 days in two of six client records.
Client #3 was admitted on May 13, 2022 and discharged on September 30, 2022. The last treatment plan update was completed on July 19, 2022. There was no treatment plan update documented in August 2022.
Client #6 was admitted on August 2, 2022 and is currently an active client. A treatment plan update was completed on August 8, 2022. The next treatment plan update was due to be completed by September 8, 2022. The treatment plan update was completed on October 19, 2022.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 16, 2021 annual licensing inspection.
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Plan of Correction
The Director met with the clinical team members on 11/7/22 and reviewed the treatment plan update timeframes. All staff were trained in how to complete the form and the frequency of completion. This plan will be monitored by the Director for compliance during daily staff meetings and weekly chart audits. |