INITIAL COMMENTS
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This report is a result of complaint investigation conducted on January 22, 2015, by staff from the Program Licensure Division. Based on the findings of the complaint investigation, the allegations made against Davis Archway House were partially substantiate and Davis Archway House 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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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 an interview with the facility director and a review of client records, the facility failed to ensure that counseling services were provided in accordance with treatment plans in two of three records reviewed.The findings include:Three client records, # 1, 2, & 3, were reviewed reviewed on 1/22/2015 to ensure that counseling services were provided in accordance with treatment plan.The facility failed to document group notes twice a week as per the treatment plans. This was discussed with the facility director during the inspection. The facility director confirmed the findings and stated that they had a problem with an employee regarding the documenting and filing of progress notes and that the employee was left go.
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Plan of Correction
The counselor responsible for the progress notes kept them in electronic format on her computer and did not follow procedure for printing and filing the note. The Clinical Supervisor, who was to perform an audit of client charts, was terminated two weeks prior due to violation of company policies and procedures.
As a result, the company hired a new Clinical Supervisor who was in the position for a short amount of time at the time of the licensing visit. The plan of correction will be for the Clinical Supervisor to continue with regular chart audits, while additionally the employees were made aware of the correct procedure for filing in the client charts at the monthly staff meeting in February. The Assistant Director will monitor compliance during weekly supervision with the Clinical Supervisor to ensure the policy is being followed.
The corrective action for this citation had been initiated by the clinical staff in February 2015, albeit the corrective action date is August 2015. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on an interview with the facility director and a review of client records, the facility failed to document how work done by the client at the project served as an integral part of their treatment.The findings include:Three client records reviewed on 1/22/2015, #1, 2, & 3, included a checkbox to indicate work therapy; however, there was nothing written that wold explain what the clients were doing and how any work they did related to their treatment. The facility director was interviewed on 1/22/2015 and he confirmed that clients were working in the kitchen since the departure of the cook in October 2014, that a client who had worked in construction done painting a the facility and that clients performed chores around the facility other than keeping their personal bedrooms cleaned. It was explained to the facility director that if clients are to be engaged in work at the facility other than keeping their own personal area clean, then it must be an integral part of their therapy and documentation as to how it relates to the therapy and the progress must be documented, or the client must be financially compensated at a fair wage.The director confirmed that the work was not documented in the clients' records as work therapy.When asked if the clients were paid for the work they did around facility, the director said they were not. The facility director was asked if the clients were compensated financially for the work they performed and he said that they were not.
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Plan of Correction
The normal operation of the facility kitchen for the past 5 years utilized a hired employee, who would be responsible for ordering, cooking and preparing daily meals. In addition, clients residing at the facility were permitted to help in the kitchen if they were on Phase 2 or Phase 3. Due to numerous complaints from the clients, it was decided we would permit the clients to prepare the meals on a trial basis. This was initiated in October of 2014 and has been on a volunteer basis for clients who are on Phase 2 or 3. At no time, were clients ever forced to work in the kitchen, it has always been on a volunteer basis since October 2014. This arrangement has worked very well since October, with the clients overwhelmingly approving of the changes.
The corrective action will be updating the facility treatment plan to allow for the indication of clients engaging in work therapy at the facility; the progress and how the work relates to the client treatment will be documented in the case consultation and treatment plan updates. These forms will be updated and reviewed with the clinical staff at the monthly staff meeting to be held September 10, 2015. The Clinical Supervisor will be responsible for monitoring the correct documentation and compliance with policy procedure. The Assistant Director will confirm compliance with these changes via weekly supervision with the Clinical Supervisor.
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