INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18-19, 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 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to prohibit heaters that are not permanently mounted or installed.
A portable heater was observed in an individual counseling office during the physical plant conducted on October 19, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility removed the space heater, all staff were instructed to not bring space heaters into the building under any conditions. The maintenance personnel will monitor this plan for compliance. |
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
The Director wrote the policy for notification of EC with 12hrs of discharge from the facility. This policy was reviewed with the nursing and clinical staff, compliance with this plan 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 15, 2021 annual licensing inspection.
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Plan of Correction
The facility had the 2021 Audit completed by Mattern CPA in November 2022. The 2022 Audit will be completed on time. |
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 one of one residential client records.
Client #6 was admitted on December 27, 2021 and involuntarily discharged from residential treatment on February 11, 2022. There was no documentation of written notification of termination in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff completing discharge notifications have been trained to complete the ASR/Involuntary Discharge Notification with the client prior to DC. This will be completed with the client and staff signature. This plan will be monitored during weekly chart audits by the Director. |
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 consultation notes, as per agency policy of seven days and every 15 days after that in seven of seven residential client records.
Client #1 was admitted on September 22, 2022 and is currently an active client. There were no case consultation notes documented in client record #1.
Client #2 was admitted on August 1, 2022 and is currently an active client. There were no case consultation notes documented in client record #2.
Client #3 was admitted on October 9, 2022 and is currently an active client. There were no case consultation notes documented in client record #3.
Client #4 was admitted on March 25, 2022 and discharged on April 28, 2022. There were no case consultation notes documented in client record #4.
Client #5 was admitted on February 2, 2022 and discharged on March 11, 2022. There were no case consultation notes documented in client record #5.
Client #6 was admitted on December 27, 2021 and discharged on February 2, 2022. There were no case consultation notes documented in client record #6.
Client #7 was admitted on August 29, 2022 and discharged on April 28, 2022. There were no case consultation notes documented in client record #7.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 15, 2021 and February 12, 2021 annual licensing inspections.
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Plan of Correction
The Director met with the clinical team members on 11/4/22 to review the required documentation list for each client. The case consultation form was reviewed along with the correct timeframe for submission. The POC will be monitored by the Director and the Lead Counselor. |
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 records, the facility failed to document a discharge summary in two of four residential client records.
Client #6 was admitted on December 27, 2021 and discharged on February 11, 2022. There was no documentation of a discharge summary in client record #6.
Client #7 was admitted on August 29, 2022 and discharged on October 1, 2022. There was no documentation of a discharge summary in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director met with the clinical team members on 11/4/22 and reviewed the discharge procedure and required documentation. Completion of the discharge summary and continuing care plan were reviewed with staff, ongoing compliance will be monitored by the Director and the Lead Counselor. |
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 case consultations was submitted and approved by the Department for the September 15, 2021 and February 12, 2021 annual licensing inspections. Case consultations was again found to be a deficiency in the October 18-19, 2022, annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure plans of correction are maintained, Davis Archway will take the following steps. The Director will actively monitor each plan of correction and will check on a monthly basis for adherence to the plan. The Director and the Lead Counselor will meet with clinical team members during supervision to discuss any deficiencies and address the employee performance. We will also continue to monitor for compliance with weekly chart audits and scoring. |