INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 23-24, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Davis Archway Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of one applicable record reviewed.
Client # 3 was admitted on 7/18/22. The client record did not contain a discharge date or a discharge summary.
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Plan of Correction
The Clinical Director reviewed the discharge policy with the clinical staff on 9/5/22. All staff are to utilize a checklist when discharging clients to assure all documents are complete. The chart identified as deficient will have the discharge summary completed by 10/10/22. This will be monitored by the Clinical Director during chart audits. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to complete an individual treatment and rehabilitation plan within five days of the client's admission, as the Intake and Admission policy, Treatment Plan procedures indicate. This occurred in four out of seven applicable client records reviewed.
Client #1 was admitted 6/3/2022 and discharged 6/30/22. The comprehensive treatment plan was dated 6/17/22.
Client #5 was admitted 4/21/22 and discharged on 7/11/22. The comprehensive treatment plan was dated 5/9/22.
Client #7 was admitted 5/10/22 and discharged 7/21/22. The comprehensive treatment plan was dated 5/16/22.
Client # 8 was admitted 7/21/22 and discharged 7/31/22. There was no documentation of a comprehensive treatment plan found in this record.
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Plan of Correction
The Clinical Director met with all clinical team members on 9/5/22 and reviewed the treatment plan timeframes. All staff were trained to formulate the treatment plan within 5 days of client admission. The plan will be monitored by the Clinical Director during chart audits from discharged clients. |
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 a review of client records, the facility failed to document treatment plan updates as the Intake and Admission policy, Treatment Plan procedures indicate in two out of seven applicable client records reviewed.
Client # 4 was admitted on 6/7/22 and discharged on 8/15/22. A master treatment plan was completed on 6/12/22. A treatment plan update was due no later than 6/26/22; however, the updated treatment plan was dated 7/7/22. From this treatment plan, an update was due no later than 7/21/22; however, the updated treatment plan was dated 8/2/22.
Client # 5 was admitted on 4/21/22 and discharged on 7/11/22. A master treatment plan was completed on 5/9/22. A treatment plan update was due no later than 5/23/22; however, the updated treatment plan was dated 5/27/22. From this treatment plan, an update was due no later than 6/10/22; however, there were no treatment plan updates documented in the client record after 5/27/22.
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Plan of Correction
The Clinical Director met with the clinical team on 9/5/22 to review treatment plan updates. All staff were trained to update treatment plans every 15 days. This plan will be monitored by the Clinical Director during chart audits. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in three out of seven records reviewed.
Client # 2 was admitted 5/23/22 and discharged 6/23/22. The comprehensive treatment plan, dated 6/3/22, indicated one individual session weekly. The progress notes indicated that the client received an individual session on 5/31/22 and 6/10/22. The progress note dated 6/17/22 was incomplete.
Client # 4 was admitted 6/7/22 and discharged 8/15/22. The comprehensive treatment plan, dated 6/12/22, indicated one individual session weekly. The progress notes indicated that the client received one individual session in June, dated 6/28/22.
Client #5 was admitted 4/21/22 and discharged on 7/11/22. The comprehensive treatment plan, dated 5/9/22, indicated one individual session weekly. The progress notes indicated that the client received three individual sessions dated 5/10/22, 6/3/22 and 6/9/22.
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Plan of Correction
The Clinical Director met with the Clinical Team on 9/5/22 and reviewed the completion of all progress notes. All staff were trained to complete the progress note immediately following the individual therapy session. The plan will be monitored by the Clinical Supervisor during chart audits. |
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 provide a complete client record, which is to include a discharge summary, in two out of seven applicable records reviewed.
Client # 4 was admitted on 6/7/22 and discharged on 8/15/22. The client record did not contain a discharge summary.
Client # 8 was admitted on 7/21/22 and discharged on 7/31/22. The client record did not contain a discharge summary.
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Plan of Correction
The Clinical Director met with the clinical team on 9/5/22. All staff were trained to use a discharge checklist that includes the discharge summary. All staff were informed of the deadline for submission. All charts identified as deficient will have the discharge summary completed by 10/10/22. This plan will be monitored by the Clinical Director during chart audits. |