INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted March 8-9, 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.
|
Plan of Correction
|
705.7 (a) LICENSURE Food service.
705.7. Food service.
(a) A residential facility shall provide meals to residents through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers.
|
Observations
Based on interviews, the facility failed to provide adequate meals to residents.
All of the clients interviewed reported that there were a few times in which there was not enough food to suffice as a meal.
This was discussed with facility staff during the complaint investigation.
|
Plan of Correction
Davis Archway investigated these issues and found the contributing factors to the kitchen running out of certain items. Due to shortages, food would often not arrive on the delivery day of the food order. In lieu of those items the Kitchen Manager would change the menu and/or go to a local store and purchase the items. Although we did run low at times there was never a time a client did not have food to eat. We also supply our clients with cereal, bagels, granola bars, etc. during snack time that has become the 4th meal of the day.
To assure we do not run low on any food; we have directed the kitchen manager to promptly inform the business manager of items that may be running low so they can be purchased. As well, the kitchen manager has been directed to take inventory twice a week to assure adequate supplies. If we are low on any items, they will be purchased locally.
The access to the kitchen after business hours has been modified to only allow staff to enter the kitchen. In the past, clients were being permitted to enter the kitchen with staff supervision. We found that clients were helping themselves to items in the kitchen and using food items reserved for other meals.
The CEO will monitor the corrective action and will meet weekly with the Kitchen Manager to assure all changes have been made.
|
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.
|
Observations
Based on a review of client charts, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client #1 was admitted 1/5/2022 and is a current client. The 3/6/2022 treatment plan update states that the client will attend daily groups and weekly individual treatment sessions. The client chart does not include progress notes for individual counseling sessions for the weeks of January 31st, February 14th and February 28th.
Client #3 was admitted 1/5/2022 and is a current client. The 3/8/2022 treatment plan update states that the client will attend daily groups and weekly individual treatment sessions. The client chart does not include progress notes for individual counseling sessions for the weeks of February 21st and 28th.
|
Plan of Correction
The Clinical Supervisor met with the clinical staff on March 23, 2022 and reviewed policy for completion of documentation. At the end of each day, the clinical team members are required to submit a list of all clinical tasks completed, including session notes and group therapy notes. The Clinical Supervisor will review each list and confirm the documentation has been entered into the client chart, as well they will conduct weekly chart audits to confirm the policy is being followed. |