INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14-15, 2021 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 the review of client records, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and /or at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training within the first year in two of two records.
Employee # 3 was hired as a counselor on June 1, 2020. The STD/TB training was due to be completed by June 1, 2021. There was no documentation the training had been completed.
Employee # 4 was hired as a counselor on August 31, 2020. The HIV/AIDS and STD/TB training were due to be completed by August 31, 2021. There was no documentation the training had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will provide the TB/STD training for the clinical staff members that have not had the required training. The Director of Nursing will provide the training to staff members by 10/22/2021.
For staff who need the HIV/AIDS training, they have been scheduled at the next available training to be held on January 19th-20th. If there are any openings prior to the January date we will sign up staff to take the training.
The Facility Director will audit employee training files each quarter to ensure the deficiency does not recur and that the corrective action plan is implemented. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on the physical plant inspection, the facility failed to store utensils in a clean enclosed area.
A physical plant inspection was conducted on September 14, 2021. In the dining area, the utensils were stored in open containers.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The kitchen manager has been made aware the silverware bins need to be covered while not in use and has informed all kitchen staff. The manager will be responsible for ensuring the utensils are in a covered container and will monitor compliance by conducting a weekly inspection of the utensil area. To ensure compliance all new staff will be trained in proper storage of all kitchenware and utensils. The Facility Director will ensure the plan of correction is implemented and maintained. |
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 the review of administrative documentation, the facility failed to obtain an annual audit for the fiscal year ending December 31, 2020.
There was no documentation that an audit had been completed for the fiscal year ending on December 31, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The audit for 2020 is currently being conducted and will be completed by 11/15/2021. The CEO will ensure the plan of correction is implemented by receiving the final audit from the CPA firm. To ensure the deficiency does not recur, the CEO will schedule the annual meeting with the CPA firm no later than May 1 of each year to begin the audit process. |
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.
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Observations
Based on the review of client records, the facility failed to obtain informed and voluntary consent that included the purpose of disclosure, in three of eleven records.
Client # 3 was admitted to detox on September 9, 2021 and was still an open client at the time of the inspection. A release to an individual, signed by the client on September 9, 2021, did not document the purpose of disclosure.
Client # 7 was admitted to detox on July 29, 2021 and transferred to inpatient on August 4, 2021. The client was still an open client at the time of the inspection. A release to a government agency, signed by the client on August 18, 2021, did not document the purpose of disclosure. A release to another treatment facility, signed by the client on September 9, 2021, did not document the purpose of disclosure.
Client # 8 was admitted to inpatient on August 10, 2021 and was still an open client at the time of the inspection. A release to an individual, signed by the client on August 10, 2021, did not document the purpose of disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/27/2021 all clinical and nursing staff have received a brief training on valid consent forms. The Clinical Supervisor reviewed the forms with the clinical team and the Director of Nursing reviewed the forms with the nursing department. This will be monitored by the Clinical Supervisor. |
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 the review of client records, the facility failed to document case consultation notes according to policy in five of seven records.
The agency policy is that case consultation notes will be completed within seven days of admission and every 30 days thereafter.
Client # 6 was admitted to inpatient on August 9, 2021 and was still an active client. A case consultation note, due to be completed by August 16, 2021, was not documented.
Client # 8 was admitted to inpatient on August 10, 2021 and was still an active client. A case consultation note, due to be completed by August 17, 2021, was not documented.
Client # 9 was admitted to inpatient on May 17, 2021 and was discharged on August 16, 2021. Case consultation notes, due to be completed by May 24, June 24, and August 24, 2021, were not documented.
Client # 10 was admitted to inpatient on May 26, 2021 and was discharged on August 23, 2021. A case consultation note, due to be completed by June 2, 2021, was not documented.
Client # 11 was admitted to inpatient on June 18, 2021 and was discharged on August 7, 2021. A case consultation note, due to be completed by July 21, 2021, was not documented.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 10, 2021 licensing inspection.
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Plan of Correction
On 9/27/2021 and 9/30/2021, the Clinical Supervisor met with the clinical team and reviewed the deficiency in completing case consultations in the required timeframe. This will be monitored by the Clinical Supervisor for compliance with the policy. |