INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 16, 2025 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:
|
Plan of Correction
|
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on applicable client records reviewed, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on the signed consent forms in one of seven records.Client #2 was admitted on April 24, 2025 and was still active at the time of the inspection. An informed and voluntary consent was signed and dated July 30, 2025, but did not include the name of the person, agency, or organization to whom disclosure is made.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director met with the clinical team members on 10/10/25 and reviewed the importance of making sure all consents are valid and include all necessary information. The Clinical Supervisor will review all client consent forms during weekly chart audits to ensure compliance with the regulation. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on applicable client records reviewed, the facility failed to document the purpose of the disclosure on the signed consent forms in three of seven records.Client #1 was admitted on April 14, 2025 and was still active at the time of the inspection. An informed and voluntary consent for a sponsor was signed and dated May 8, 2025, but did not include the purpose of the disclosure.Client #3 was admitted on June 17, 2025 and was still active at the time of the inspection. An informed and voluntary consent for a pharmacy was signed and dated June 17, 2025, but did not include the purpose of the disclosure.Client #6 was admitted on December 3, 2024 and was discharged June 2, 2025. An informed and voluntary consent for an emergency contact was signed and dated December 3, 2024, however the purpose just stated " ec. "An informed and voluntary consent for an agency was signed and dated December 3, 2024, but did not include the purpose of the disclosure.An informed and voluntary consent for an agency was signed and dated December 3, 2024, but did not include the purpose of the disclosure.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director met with the clinical team members on 10/10/25 and reviewed the importance of documenting the purpose of disclosure on the consent form. The Clinical Supervisor will review all consents during weekly chart audits to ensure the purpose of disclosure is included in each consent. The plan of correction will be monitored by the Executive Director 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.
|
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 five applicable records.Client #1 was admitted on April 14, 2025 and was still active at the time of the inspection. A treatment plan update was completed on May 27, 2025. The next update was due no later than June 27, 2025; however, it was not completed until July 1, 2025. The next update was due no later than August 1, 2025; however, it was not completed until August 20, 2025.Client #2 was admitted on April 24, 2025 and was still active at the time of the inspection. A treatment plan update was completed on May 30, 2025. The next update was due no later than June 30, 2025; however, it was not completed until July 4, 2025. Client #3 was admitted on June 17, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 24, 2025. A treatment and rehabilitation plan update was due no later than July 24, 2025, but was not completed until September 1, 2025.Client #6 was admitted on December 3, 2024 and was discharged June 2, 2025. A treatment and rehabilitation plan was developed on December 11, 2024. A treatment and rehabilitation plan update was due no later than January 11, 2025, but was not completed until January 20, 2025.The next update was due no later than February 20, 2025; however, it was not completed until March 5, 2025.The next update was due no later than April 4, 2025; however, it was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director met with the clinical team on 10/10/25 and reviewed the company policy for updating treatment plans in the required timeframe. The Clinical Supervisor will review treatment plan updates during weekly chart audits to ensure completion with 30 days. The Executive Director will monitor to ensure compliance. |
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.
|
Observations
Based on a review of client records, the facility failed to document case consultations in four of six applicable records. The facility's policy and procedure manual states a case consultation must be completed within fifteen days of admission then every thirty days.Client #1 was admitted on April 14, 2025 and was still active at the time of the inspection. The fifteen day case consultation was due no later than April 29, 2025; however, this was completed on May 15, 2025.Client #2 was admitted on April 24, 2025 and was still active at the time of the inspection. A case consultation was completed on May 29, 2025. The next case consultation was due no later than June 29, 2025; however, this was not completed until July 28, 2025. Client #3 was admitted on June 17, 2025 and was still active at the time of the inspection. A case consultation was completed on July 3, 2025. The next case consultation was due no later than August 3, 2025; however, this was not completed until August 25, 2025.Client #6 was admitted on December 3, 2024 and was discharged June 2, 2025. A case consultation was completed on January 15, 2025. The next case consultation was due no later than February 15, 2025; however, this was not completed until February 24, 2025.The next case consultation was due no later than March 26, 2025; however, this was not completed until April 23, 2025.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Executive Director met with the clinical team on 10/10/25 and reviewed the policy for completing case consultations in the required timeframe. The Clinical Supervisor will monitor the completion of case consultations during weekly chart audits. The Executive Director will monitor the plan to ensure compliance. |