INITIAL COMMENTS
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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 House 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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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.
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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.
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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 our staff 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 ensure we do not run low on any food, we have directed the staff to promptly inform the Executive Director or the Client Coordinator of items that may be running low so they can be purchased. Also, the staff have been directed to take inventory 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 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 ensure all changes have been made.
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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 charts, the facility failed to review and update client individual treatment and rehabilitation plans every 30 days.
Client #6 was admitted on 12/17/2021 and is a current client. The initial treatment plan was dated 12/17/2021. The master treatment plan was dated 12/24/2021. A 30 day treatment plan update was not done for January and February 2022.
This was discussed with facility staff during the complaint investigation.
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Plan of Correction
The Executive Director met with all clinical team members to review company policy for completion of client documents. The staff was directed to complete all treatment plan updates within the 30 day timeframe. This will be monitored for compliance by the Director by conducting weekly chart audits of all treatment plans. |
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 charts, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client #4 was admitted on 1/13/2022 and is a current client. The 2/24/2022 treatment plan 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 14th and February 21st.
Client #6 was admitted on 12/17/2021 and is a current client. The 12/24/2021 master treatment plan 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 21st and February 28th.
This was discussed with facility staff during the complaint investigation.
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Plan of Correction
The Executive Director will have the electronic chart document amended to reflect the written company policy of conducting individual sessions every two weeks. All clinical staff were directed to continue providing individual sessions every two weeks, per company policy. The Director will be responsible for assuring the electronic record correction has been made by 4/10/2022. |