INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted March 22-23, 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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709.24 (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 the Intake and Admission policy and the Treatment Rehabilitation Management Inpatient policy, the facility failed to have clear written procedures for the frequency of individual counseling sessions.
The Intake and Admission policy states that each client should have one hour of individual counseling two times per week.
The Treatment Rehabilitation Management Inpatient policy states that individual therapy of 45 - 60 minutes are to be conducted at least once a week.
This was discussed with facility staff during the investigation.
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Plan of Correction
The Policy and Procedure Manual has been updated by the Director to reflect uniform policy for individual sessions within the Intake and Admission and the Treatment Rehabilitation Management sections. The manual was updated on 4/25/23. This information was shared with our clinical team and will be monitored by the Clinical Supervisor to assure the policy is followed as written. |
709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
Based on a review of personnel files and the Personnel Management policy, the facility failed to follow their policy regarding supervision of staff. Supervision documentation was missing from seven out of seven personnel files reviewed.
The Personnel Management policy indicates that the clinical supervisor shall maintain direct supervision of the clinical staff. The facility director shall oversee the support staff.
The facility director is currently acting in the role of clinical supervisor.
Supervisory documentation was missing from all seven files reviewed.
This was discussed with facility staff during the investigation.
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Plan of Correction
All supervision notes were located in the Directors office during the on site visit, however the Director was not at the facility and the files were not accessible. By 5/8/23, the Director will move the training binders with supervision notes into the Administrator's office to assure those files will be accessible at any time they are needed. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client charts and the Intake and Admission policy, the facility failed to develop an individual treatment and rehabilitation plan according to their policy in five out of seven applicable records reviewed. Per the Intake and Admission policy, the individual treatment and rehabilitation plan shall be developed with each client upon completion of the psychosocial evaluation within 3 days of admission.
Client 1 was admitted on 2/7/2023 and discharged on 3/6/2023. The initial treatment plan was dated 2/7/22 and the master treatment plan was dated 2/14/23.
Client 2 was admitted on 2/8/2023 and discharged on 3/2/2023. The initial treatment plan was dated 2/8/23 and the master treatment plan was dated 2/28/23.
Client 3 was admitted on 2/3/2023 and discharged on 2/21/2023. The initial treatment plan was dated 2/3/23 and the master treatment plan was dated 2/18/23.
Client 4 was admitted on 3/6/2023 and discharged on 3/21/2023. The initial treatment plan for detox was dated 3/6/23, the initial treatment plan for inpatient rehabilitation was dated 3/14/23. There was no documentation of a master treatment plan.
Client 6 was admitted on 1/10/2023 and was a current client at the time of the investigation. The initial treatment plan was dated 1/11/23 and the master treatment plan was dated 1/19/23.
Client 7 was admitted on 12/9/22 and was a current client at the time of the investigation. The initial treatment plan was dated 12/9/22 and the master treatment plan was dated 12/22/22.
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Plan of Correction
The Director met with the clinical team on 4/10/23 and reviewed the timeframes for completion of the rehabilitation plan. All team members will be advised of the specific completion dates for the rehabilitation plan after completion of the psychosocial evaluation with clients. This plan will be monitored for compliance by the Director by reviewing client records during weekly chart audits. |
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 charts, the facility failed to include the frequency of the treatment and rehabilitation services in four out of eight applicable charts reviewed.
Client 3 was admitted on 2/3/2023 and discharged on 2/21/2023. The treatment and rehabilitation plan dated 2/18/2023 did not include the frequency of group counseling.
Client 5 was admitted on 1/26/2023 and was a current client at the time of the investigation. The treatment and rehabilitation plan dated 2/7/2023 did not include the frequency of individual counseling.
Client 6 was admitted on 1/10/2023 and was a current client at the time of the investigation. The treatment and rehabilitation plan dated 1/19/2023 did not include the frequency of group counseling.
Client 7 was admitted on 12/9/2022 and was a current client at the time of the investigation. The treatment and rehabilitation plan dated 12/22/2022 did not include the frequency of individual counseling.
This was discussed with facility staff at the time of the investigation.
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Plan of Correction
The Director met with the clinical team on 5/5/23 and reviewed the treatment plan deficiencies. All team members were directed to make sure the treatment plan specifies the type and frequency of services that are individualized for each client. The Director will monitor the plan by conducting 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 a review of client charts and the Intake and Admission policy, the facility failed to document treatment plan updates every 30 days as required in two out of three applicable charts reviewed.
Client 6 was admitted on 1/10/2023 and was a current client at the time of the investigation. A treatment plan update was completed on 2/18/23 and the next update was due no later than 3/20/23; however, there was no update documented in the record at the time of the investigation.
Client 7 was admitted on 12/9/22 and was a current client at the time of the investigation. A treatment plan update was completed on 2/7/23 and the next update was due no later than 3/9/23; however, there was no update documented in the record at the time of the investigation.
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Plan of Correction
The Director met with the clinical team members on 4/10/23 and reviewed the timeline for completion of treatment plan updates. The plan will be monitored by the Director by reviewing client charts during weekly chart audits to ensure compliance. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records, the facility failed to provide counseling sessions on a regular and scheduled basis. Documentation of regularly scheduled counseling sessions was missing from five out of seven applicable charts. The Treatment Rehabilitation Inpatient policy states that individual sessions are to be done at least once a week.
Client 1 was admitted on 2/7/2023 and discharged on 3/6/2023. There were no counseling sessions documented during the weeks of 2/13/2023 and 2/27/2023 and no information as to why they did not occur.
Client 3 was admitted on 2/3/2023 and discharged on 2/21/2023. There were no counseling sessions documented during the week of 2/13/23 and no information as to why there was no session that week.
Client 5 was admitted on 1/26/2023 and was a current client at the time of the investigation. There were no counseling sessions documented during the week of 2/24/2023 and 3/17/2023 and no information as to why they did not occur.
Client 6 was admitted on 1/10/2023 and was a current client at the time of the investigation. There were no counseling sessions documented during the weeks of 1/16/2023, 1/30/2023, 2/6/23, 2/13/23, 2/20/23, 2/27/23, 3/6/23 and 3/13/23 and no information as to why they did not occur.
Client 7 was admitted on 12/9/2022 and was a current client at the time of the investigation. There were no counseling sessions documented during the weeks of 1/23/2023, 2/6/2023, 2/20/2023, 3/6/2023, and 3/13/2023 and no information as to why they did not occur.
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Plan of Correction
The Director met with the clinical team members on 4/10/23 and reviewed the importance of documentation of all client sessions. The clinical team was reminded that 2 previous clinical team members were recently terminated for failure to perform essential functions of the position, namely documentation of sessions and keeping updated records. The Director will monitor the plan during weekly chart audits to ensure individual session notes are completed. |
709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of client charts, the facility failed to provide a complete client record, which is to include progress notes, in five out of eight applicable charts.
Client 1 was admitted on 2/7/2023 and discharged on 3/6/2023. There was no individual progress notes during the weeks of 2/13/2023 and 2/27/2023.
Client 3 was admitted on 2/3/23 and discharged on 2/21/23. There was no individual progress note during the week of 2/13/23.
Client 5 was admitted on 1/26/2023 and was a current client at the time of the investigation. There was no individual progress notes during the week of 2/24/2023. Also, the progress note dated 3/17/2023 was blank.
Client 6 was admitted on 1/10/2023 and was a current client at the time of the investigation. There is no individual progress notes from the week of 1/16/2023. Additionally, there were no individual progress notes in the chart since the last one dated 1/27/2023.
Client 7 was admitted on 12/9/2022 and was a current client at the time of the investigation. There was no individual progress notes during the weeks of 1/23/2023, 2/6/2023, 2/20/2023, 3/6/2023, and 3/13/2023.
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Plan of Correction
The Director met with the clinical team members on 4/10/23 and reviewed the importance of documentation of all client sessions. The clinical team was reminded that 2 previous clinical team members were recently terminated for failure to perform essential functions of the position, namely documentation of sessions and keeping updated records. The Director will monitor the plan during weekly chart audits to ensure individual session notes are completed for each client at least once per week. |
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 charts the facility failed to ensure a complete client record, which includes case consultation notes, in eight out of the eight charts reviewed. The facility's Intake and Admission policy indicates that case consultations are to be conducted within the first seven days of admit and every fifteen days thereafter. Case consultation documentation was missing from all eight of the reviewed charts.
Client 1 was admitted on February 7, 2023 and discharged on March 6, 2023
Client 2 was admitted on February 8, 2023 and discharged on March 2, 2023
Client 3 was admitted on February 3, 2023 and discharged on February 21, 2023
Client 4 was admitted on March 6, 2023 and discharged on March 21, 2023.
Client 5 was admitted on January 26, 2023 and was still active at the time of the investigation.
Client 6 was admitted on January 10, 2023 and was still active at the time of the investigation.
Client 7 was admitted on December 9, 2022 and was still active at the time of the investigation.
Client 8 was admitted on January 5, 2023 and discharged on January 14, 2023.
This was discussed with facility staff during the investigation.
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Plan of Correction
The Director met with the clinical team members on 5/2/23 and reviewed the importance of documenting case consultations in the client record. The clinical team was reminded that 2 previous clinical team members were recently terminated for failure to perform essential functions of the position, namely documentation of case consultations and keeping updated records. The Director will monitor the plan during weekly chart audits to ensure case consultations are being documented per company policy. |
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, the facility failed to ensure a complete client record to include a discharge summary in one of the five applicable charts.
Client 2 was admitted on 2/8/2023 and discharged on 3/2/2023. The client record did not contain a discharge summary.
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Plan of Correction
The Director met with the clinical team members on 4/10/23 and reviewed the importance of completing the discharge summary. The Director will monitor the plan during weekly chart audits to ensure the summary is completed. The discharge summary for Client 2 will be created and updated to reflect the discharge information. |