INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2022 through August 17, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Interim House West 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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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
On August 17, 2021, at approximately 10:35 AM, the bathroom in room 304 B had a broken toilet that did not flush and a cracked toilet seat, which exposed sharp edges.
This is a repeat citation from the August 12, 2021 and February 11, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/17/2022 the cracked toilet seat were replaced and a new toilet flap were placed on the toilet by the end of the working day. Facility Manager will provide client with instruction on how to complete repair slips during her weekly household management group. Facility Manager and PHMC Facility will collaborate daily on any disrepair items that needs to be repair. All repair slip will be given to the facility Manager and Facility Manager will notify PHMC Facility of the repair the same day of receiving the repair slips. Facility Manager will express during her weekly Household management group the important of informing staff of any repairs. During clients morning check-in staff will ask clients about any repairs that needed in their unit. All room will be monitor by the facility Manager for any repairs. PHMC Facility will do a Quarterly walk through to ensure that the IHW physical plant is safe |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made to on consent to release information forms in two of seven client records reviewed.
Client #4 was admitted on December 2, 2021 and was discharged on March 14, 2022. The release of information forms to an outside contact, a funding source and an emergency contact were signed and dated by the client on December 7, 2021, but all the release forms did not include the name of the person, agency, or organization to whom the disclosure is made to.
Client #7 was admitted on February 22, 2022 and was active at the time of inspection. The release of information form to the funding source was signed and dated by the client on February 22, 2022, but the release form did not include the name of the person, agency, or organization to whom the disclosure is made to.
This is a repeat citation from the August 12, 2021 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/7/2022 IHW conducted a review of the participant chart and share with the participant the information that were missing from the incomplete Authorization for release of information documentation form. The incomplete authorization to release information was updated with insurance carrier listed on 9/8/2022
All Staff who use ROI and who assist participants to complete Authorizations for Release of Information (ROI) will be re-trained in with the DDAP Confidentiality training, which includes information about completing ROI by 9/30/2022. In addition, staff that was trained in the August 12, 2021, will be POC by 9/30/2022
IHW is implementing this new procedure effective immediately 9/9/2022:
All ROI, (e.g., ROI in the Admission Intake Packets or completed with assistance from Case Management staff) will be reviewed by the Admissions Coordinator and Clinical Director after they are completed (e.g., after each admission/ intake session / case management intake session, or any other time that ROI are completed). ROI will be reviewed for Completion and Compliance by the Admission Coordinator and Clinical Director prior to being entered into the client record. Incomplete or non-compliant ROI documents will be returned to the staff member submitting the materials to correct or re-do with the program participant. Admissions Coordinator or Clinical Director will file complete and compliant reviewed ROI into the client file.
In addition, Program Director has re-trained the Clinical Director in the August 12, 2021, POC on 9/9/2022:
Clinical Director will conduct clinical chart reviews weekly to ensure ROI are completed correctly. All issues with ROIs will be addressed immediately after chart audit by Clinical Director. Clinical Director will also address any concerns with staff as it pertains to ROI during weekly supervision and provide on-going training as needed.
Program Director will ensure and monitor compliance with the new procedure and the POC from August 12, 2021, during regular (e.g., weekly) supervision meetings with the Clinical Director and by reviewing regular chart monitoring's completed by the Clinical Director.
Program Director will also including a standing agenda item of reviewing DDAP approved state licensing POCs for facility compliance during regular supervision meetings with the Managing Director of Addiction Services. Any facility non-compliance with DDAP approved state licensing POCs will be addressed by the Program Director and Managing Director during this supervision meeting and addressed by the Managing Director with Department Head Leadership if needed for follow-up, for example with training, monitoring, or staff discipline per corporate policy.
In addition, to ensure and monitor compliance with the DDAP approved state licensing POCs, the POCs will be included in regular Corporate Quality Department facility compliance inspections (e.g., quarterly). The Program Director will review the Quality Department findings, including any findings of POC non-compliance, after each regular Quality Department inspection. Program Director will follow-up with any identified issues of ROI non-compliance issues immediately upon discovery with program staff with training or staff discipline per corporate policy.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of seven client records reviewed.
Client #4 was admitted on December 2, 2021 and was discharged on March 14, 2022. The release of information form to another treatment provider was signed and dated by the client and witness on March 1, 2022, but the release form did not include the specific information to be disclosed.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director and PHMC organization development and learning department will provide a mandatory staff training to review 709.28 (c) (2) regulations as it pertains to informed and voluntary consent. PHMC organization development and learning department, along with the clinical director will address the importance of documenting specific information that is being disclosed. Clinical Director will also review staff individual training plans to ensure that all staff have completed DDAP confidentiality training. The training will be held on 9/12/22. All required new staff will complete the DDAP Confidentiality training within 180 days of hire. |
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 a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in two of seven client records reviewed.
Client #1 was admitted on August 6, 2021 and was discharged on August 27, 2021. The release of information form to an outside contact was signed by the client on August 11, 2022, but the release form did not include the purpose of the disclosure.
Client #4 was admitted on December 2, 2021 and was discharged on March 14, 2022. The release of information forms to a human service agency and a housing authority were signed by the client on December 7, 2021, but both release forms did not include the purpose of the disclosure.
This is a repeat citation from the August 12, 2021 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director/PHMC organization development and learning department will provide a mandatory staff training to review 709.28 (c) (3) regulations as it pertains to client record in which the consent must be in writing and include, but not be limited to purpose of disclosure. The training will address the importance of specifying the purpose of disclosure information. Clinical director and PHMC organization development/learning department will conduct charts audits to ensure that all information disclosure properly to adhere to 709.28 (c) (3) regulations. PHMC organization development/learning department will monitor charts and conduct audits quarterly to ensure consent forms are completed correctly. All required new staff will complete the DDAP Confidentiality training within 180 days of hire. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of a client on informed and voluntary consent to release information forms in one of seven client records reviewed.
Client #4 was admitted on December 2, 2021 and was discharged on March 14, 2022. There was a release of information form to an unidentified, external contact signed by the witness on December 7, 2021; however, the release form did not include the signature of the client.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director and PHMC organization development and learning department will provide a mandatory training by 9/12 /22 for all staff to ensure that 709.28 (c ) (4) is done correctly. this training will focus on obtain an informed and voluntary consent from client for disclosure of information contained in the client record. During this training the focus will also be on ensuring that the date of signature of client or guardian and it must be in writing. PHMC organization development and learning department team will review the written consent during their regular quarterly chart review to ensure that all information is correct. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of consent to release information forms were offered to the client in one of seven client records reviewed.
Client #5 was admitted on April 22, 2022 and was still active at the time of the inspection. The release of information form to another treatment provider was signed by the client on July 29, 2022; however, there was no documentation indicating a copy of the release form was offered to the client. Additionally, the release of information form to a health services clinic was signed by the client on April 23, 2022; however, there was no documentation indicating a copy of the release form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
IHW conducted a review of the participant chart for the incomplete Authorization for release of information documentation form. IHW conducted a review of information sharing activities for the participant on 9/7/2022; reviewing information shared about this participant and discovered that all information sharing to outside entities was conducted with completed authorization to release information documents from the file. No information was shared to outside entities using the incomplete authorization to release information document referenced by the audit. The incomplete authorization to release information form was removed from the file as of 9/7/2022 and the participant, who was discharged on 8/29/2022, was notified by telephone on 9/7/2022 that an incomplete authorization to release information documents with an unnamed release in the file was removed and destroyed, and that it was not used for any information sharing. The client was informed that if they intended for IHW to release information to a 3rd party, they may contact IHW and come to the facility to completed and sign a new authorization to release information form. The clinical director and PHMC organization development and learning department will provide a mandatory training by 9/12 /22
for all staff to ensure that 709.28 confidentiality, the training will include instruction offered the clients a copy the consent and a copy is placed in the client record. Program Director will review staff individual training plans to ensure that all required staff have completed DDAP confidentiality training with in 180 days of hire. PHMC organization development and learning department team will review the written consent during their regular quarterly chart review to ensure that all information is correct. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the unusual incident report logs, the facility failed to file a written unusual incident report with the Department within three business days following several incidents involving the physical assault by staff or a client.
The unreported incidents occurred on the following dates: August 16, 2021, October 30, 2021, December 4, 2021, December 21, 2021, and December 26, 2021
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC has an Internal Electronic System in place in which all unusual incidents are reported to PHMC data base and sent to appropriate agencies that requires unusual incidents reporting. Program Director and Clinical Director will meet and train all staff regarding 709.34 (c) (1) unusual incidents reporting which involve physical assault by staff or a client. Staff will be informed of the time frame in which unusual incidents reporting should be done. This meeting/training will occur on 9/7/2022. Clinical Director will be responsible for ensuring that 709.34 (c) (1) unusual incidents reporting and the type of incidents to report is being reported. Clinical Director will inform staff of the time frame in which unusual incidents reporting should be done. The person who is completing the incident report will send the report to PHMC internal electronic system and provide the information to the Clinical Director who will report the unusual incidents in DDAP data base with in 72hours to ensure that the unusual incidents are reported. Program Director monitor all Unusual Incidents is being reported during supervision with Clinical Director. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the unusual incident report logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility on September 2, 2021.
This is a repeat citation from the August 12, 2021 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will be responsible for ensuring that 709.34 (c) (4) unusual incidents reporting and the type of incidents to report is being reported. Clinical Director will inform staff of the time frame in which unusual incidents reporting should be done. The person who is completing the incident report will send the report to PHMC internal electronic system and provide the information to the Clinical Director who will report the unusual incidents in DDAP data base with in 72hours to ensure that the unusual incidents are reported. Program Director monitor all Unusual Incidents is being reported during supervision with Clinical Director. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.
Client #1 was admitted on August 6, 2021 and was discharged on August 27, 2021
Client #2 was admitted on August 19, 2021 and was discharged on September 16, 2021.
Client #3 was admitted on September 16, 2021 and discharged on October 11, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.53 (a) (11) Interim House West as an Internal system in which a client complete record identifies client's involvement with the project. The clinical director and program director will provide a training with the case manager (s) to ensure that clients are receiving follow-up calls and information on the 7th, 14th, 30th, 90th day and 6months after discharged. Clinical Director will review with case manager (s) weekly during supervision to ensure all follow-up are done accordance to 709.53 (a) (11) code. Clinical Director will review this process with case manager by 9/6/2022 |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a physical plant inspection, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for maintaining each bathroom in a functional, clean, and sanitary manner at all times were submitted and approved by the Department for the August 12, 2021 and February 11, 2021 annual licensing inspections. Maintaining each bathroom in a functional, clean, and sanitary manner at all times was again found to be a deficiency in the August 16, 2022 to August 17, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will train staff in following DDAP approved state licensing Plans of Correction (POCs) during the next scheduled regular staff meeting by 9/16/2022. Program Director will including a standing agenda item of reviewing DDAP approved POCs for compliance during regular (e.g., weekly) facility staff meetings. Any non-compliance with DDAP approved state licensing POCs will be addressed during facility staff meeting and during regular individual staff supervision meetings with the staff assigned to conduct POCs with training or staff discipline per corporate policy.
Program Director will also including a standing agenda item of reviewing DDAP approved state licensing POCs for facility compliance during regular supervision meetings with the Managing Director of Addiction Services. Any facility non-compliance with DDAP approved state licensing POCs will be addressed by the Program Director and Managing Director during this supervision meeting and addressed by the Managing Director with Department Head Leadership for follow-up, for example with training or staff discipline per corporate policy.
In addition, to ensure and monitor compliance with the DDAP approved state licensing POCs, the POCs will be included in regular PHMC Quality Department facility compliance inspections (e.g., quarterly). The Program Director will review the Quality Department findings, including any findings of POC non-compliance, after each regular Quality Department inspection. Program Director will follow-up with any identified issues of ROI non-compliance issues immediately upon discovery with program staff with training or staff discipline per corporate policy.
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