INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17, 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 Treatment Center 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in four of seven staff records.Staff #7 was hired as a support staff on December 19, 2022 and was still in this position at the time of the inspection. HIV/AIDS and TB/STD trainings were to be completed by December 19, 2024. There was no documentation that these trainings were completed.Staff #8 was hired as a support staff on July 28, 2023 and was still in this position at the time of the inspection. HIV/AIDS and TB/STD trainings were to be completed by July 28, 2025. There was no documentation that these trainings were completed.Staff #9 was hired as a support staff on March 23, 2022 and was still in this position at the time of the inspection. HIV/AIDS and TB/STD trainings were to be completed by March 23, 2024. There was no documentation that these trainings were completed.Staff #10 was hired as a support staff on June 15, 2022 and was still in this position at the time of the inspection. HIV/AIDS and TB/STD trainings were to be completed by June 15, 2024. There was no documentation that these trainings were completed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director provided the required HIV and TB/STD training to the support staff members on 10/15/2025. The HR Manager will track the required training dates for support staff to ensure they are completed on time. The Clinical Director will monitor the plan every 30 days to ensure compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the personnel training records, the facility failed to have the counselor complete at least twenty-five clock hours of annual training in one of two applicable records. Staff #3 was hired as a counselor on July 10, 2023. Staff #3 documented twenty-two hours of training for the July 1, 2024 to June 30, 2025 training year.This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the October 1, 2024 annual licensing inspection.
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Plan of Correction
The Clinical Director reviewed training plan schedules with the clinical team during weekly supervision on 10/13/25. Every 30 days the Clinical Director and counselor will meet to review the training plan to ensure training hour requirements are met. The CEO will monitor the plan to ensure compliance. |
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 applicable client records reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in one of two recordsClient #11 was admitted to inpatient on June 10, 2025 and discharged on July 16, 2025. There was no documentation in the client record notifying the client in writing of termination from the project.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director provided the nursing department and the administrative assistant with the required forms to provided to clients regarding involuntary termination from treatment. The administrative assistant is tracking completion of the forms for all involuntary terminations. The plan will be monitored every 30 days by the Clinical Director 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 three of four applicable records.Client #8 was admitted to inpatient on July 31, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 6, 2025. A treatment and rehabilitation plan update was due no later than September 6, 2025, but was not completed until September 11, 2025.Client #10 was admitted to inpatient on July 17, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on July 27, 2025. A treatment and rehabilitation plan update was due no later than August 27, 2025, but was not completed until August 28, 2025.Client #13 was admitted to inpatient on May 2, 2025 and was discharged on August 5, 2025. A treatment and rehabilitation plan was developed on May 12, 2025. A treatment and rehabilitation plan update was due no later than June 12, 2025, but was not completed until July 1, 2025.The next update was due no later than August 1, 2025, but this was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 1, 2024 and September 20, 2023 annual licensing inspections.
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Plan of Correction
The Clinical Director created a tracking document for all clients to be reviewed at the morning clinical meeting. The Clinical Director will ensure completion of the treatment plan update by reviewing the record during the meeting. The Executive Director will also assist with weekly chart audits 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.
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Observations
Based on a review of client records, the facility failed to document case consultations in three of seven applicable records. The facility's policy and procedure manual states a case consultation must be completed within ten days of admission then every thirty days.Client #12 was admitted to inpatient on June 20, 2025 and was discharged on July 28, 2025. A case consultation was completed on June 26, 2025. The next case consultation was due no later than July 26, 2025; however, this was not completed prior to discharge.Client #13 was admitted to inpatient on May 2, 2025 and was discharged on August 5, 2025. A case consultation was completed on May 7, 2025. The next case consultation was due no later than June 8, 2025; however, this was not completed until June 10, 2025. The next case consultation was due no later than July 10, 2025; however, this was not completed until July 28, 2025.Client #14 was admitted to inpatient on May 30, 2025 and was discharged on August 15, 2025. The ten-day case consultation was due no later than June 9, 2025; however this was not completed until June 19, 2025. The next case consultation was due no later than July 19, 2025; however, this was not completed prior to discharge.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from the October 1, 2024 annual licensing inspection.
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Plan of Correction
The Clinical Director created a tracking document for all clients to be reviewed at the morning clinical meeting. The Clinical Director will ensure completion of the case consultation form by reviewing the record during the meeting. The Executive Director will also assist with weekly chart audits to ensure compliance. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on applicable client records reviewed, the facility failed to complete an aftercare plan in accordance with the facility policy and procedure manual in one of two records. The facility policy and procedure manual indicated an aftercare plan will be completed with the client for all planned discharges. Client #13 was admitted to inpatient on May 2, 2025 and was discharged on August 5, 2025. An aftercare plan was not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director provided the clinical team members with a discharge sign off sheet for all discharges to confirm all required documents are completed. The Aftercare Coordinator will confirm all documents are completed by auditing all discharges from the facility. The plan will be monitored every 30 days by the Clinical Director to ensure compliance. |
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 applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual in two of four records. The policy and procedure manual indicates a discharge summary be completed within seven days of discharge.Client #11 was admitted to inpatient on June 10, 2025 and discharged on July 16, 2025. The discharge summary was due to be completed no later than July 23, 2025; however, this was not completed at the time of the inspection.Client #14 was admitted to inpatient on May 30, 2025 and was discharged on August 15, 2025. The discharge summary was due to be completed no later than August 22, 2025; however, this was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 1, 2024 annual licensing inspection.
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Plan of Correction
The Clinical Director provided the clinical team members with a discharge sign off sheet for all discharges to confirm the discharge summary is complete. The Aftercare Coordinator will confirm all documents are completed by auditing all discharges from the facility. The plan will be monitored every 30 days by the Clinical Director 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 updates was submitted and approved by the Department for the October 1, 2024 and September 20, 2023 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the September 17, 2025 annual licensing inspection.This was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility has developed mechanisms and oversight to ensure all plans of correction are initiated and maintained. The Clinical Director is utilizing spreadsheets with due dates for all required documents to ensure timely completion. The Executive Director is also conducting weekly chart audits to ensure compliance. |