INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11-13, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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709.34 (c) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
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Observations
The facility failed to notify the Department within 3 business days of a November 16, 2018 incident which closed the facility for more than one day. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility was closed November 16-20, 2018 due to loss of power. We notified DDAP by phone but failed to send a written report within three business days. As a result, the Facility Director met with the clinical staff to review all policies and procedures for notification to DDAP and other entities. As well, the Facility Director and the Assistant Director reviewed the 709.34 regulations to ensure future notifications will meet the required time frame. |