INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on November 14-15, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Interim House West was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection completed on November 14, 2023, the facility failed to keep the building clean, safe, sanitary and in good repair at all times.
The basement was observed to have water damaged ceiling tiles. One of the tiles had disintegrated and pieces of the tile were on the floor. Two buckets were observed to be under the damaged ceiling tiles to catch leaks.
Broken slats were observed on one of the dining room blinds.
Ceiling paint was peeling from the first floor client bathroom.
The first floor pre-school room had a black mold-like substance on the wall with chipped paint on the windowsills and peeling paint on the walls.
Second Floor hallway tile is cracked and chipped. Also, the hallway was observed to have dirt, paper, dust and debris.
|
Plan of Correction
Plan of Correction:
The issues identified by the DDAP inspector (basement water damaged ceiling tiles; Dining room blinds broken slats; bathroom Ceiling paint peeling; pre-school room substance, chipped/ peeling paint; hallway tile dirt) were each sent to the Facilities department for resolution and were resolved by 12/31/2023.
All staff and supervisors will be trained by the Program Director on the 705.2 (2) Building exterior and grounds requirement, including that the residential facility shall keep the grounds of the facility clean, safe, sanitary and in good repair at all times.
All staff are responsible to bring any issues of facility cleanliness, safety, sanitation, and/or repair to the immediate attention of the Facility Manager. The Facility Manager will conduct regular (e.g. daily) grounds checks, and will provide a weekly report to the Program Director during regular (e.g. weekly) supervision meetings. At this meeting the IHW facility manager will report any issues of cleanliness, safety, sanitation, and/or repair issues to the Program Director for internal Plan of Correction, and will create and send any correction issues to PHMC facilities when appropriate. Issues requiring immediate attention will be brought immediately to the attention of the Program Director by the facility manager for internal Plan of Correction, and any correction issues will be sent to PHMC facilities department immediately when appropriate. .
|
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.
|
Observations
The facility failed to inform the Department of an unusual incident involving the presence of ambulance personnel within the required three days. During a complaint investigation, an ambulance was observed to be on site 11/14/23. No unusual incident report has been submitted to the Department for this occurrence.
|
Plan of Correction
All staff and supervisors will be trained by 01/30/2024 by the Program Director on the 709.34. Reporting of unusual incidents requirement, including that the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving: Event at the facility requiring the presence of police, fire or ambulance personnel.
The Program Director will ensure that incidents are filed with the Department within 3 business days following an unusual incident involving: Event at the facility requiring the presence of police, fire or ambulance personnel, using the Department Incident reporting instructions and guidelines.
|
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on client chart reviews on November 15, 2023, the facility failed to document the type and frequency of services on treatment plans in 3 of 6 charts reviewed.
Client # 1 was admitted 10/5/22 and was still an active client at the time of the investigation. The treatment plan dated 5/3/23 indicated the client was to have 1 individual session. The frequency of group sessions was not documented.
Client # 3 was admitted 11/9/22 and was still an active client at the time of the investigation. The treatment plan dated 10/22/23 indicated the client was to have 1 individual session per week. The frequency of group sessions was not documented.
Client # 5 was admitted 12/13/22 and discharged 5/30/23. The comprehensive treatment and rehabilitation plan dated 1/10/23 was missing the frequency of group therapy.
|
Plan of Correction
All staff and supervisors will be trained by 01/30/2024 by the Program Director on the 709.52(a)(2) Licensure
Tx type & frequency Treatment and rehabilitation services requirements, including that An
individual treatment and rehabilitation plan shall be
developed with a client. The plan shall include, but not be limited to, written documentation of Type and frequency of treatment and rehabilitation services.
The Clinical Supervisor will prepare and review the schedule of clinical services with the Program Director on a weekly basis, and present the schedule at the weekly Clinical Team meeting . The Clinical Supervisor will ensure that clinical sessions are occurring according to the Treatment Plan requirements on the weekly schedule. The Clinical Supervisor will review and provide feedback for compliance , the Documentation of Treatment Plans and Clinical treatment sessions during regular (e.g. bi-monthly ) individual Supervision meetings with the clinicians. The Clinical Supervisor will present progress with meeting 709.52(a)(2) requirements to the Program Director during regular (e.g. monthly Supervisor meetings). The PHMC Compliance Department will review Client charts for compliance with the 709.52(a)(2) requirement during regular (e.g. bi-annual) Compliance chart reviews. Results of Compliance chart reviews will be shared with the Program Director for follow-up.
|
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.
|
Observations
Based on client chart reviews on November 15, 2023, the facility failed to document treatment plan reviews and updates at least every 30 days in 5 of 6 charts reviewed.
Client # 1 was admitted 10/5/22 and was still an active client at the time of the investigation. The last treatment plan update was dated 5/3/23. Treatment plan updates were missing for June 2023 through November 2023.
Client # 2 was admitted on 11/3/22 and discharged on 11/8/23. The last treatment plan update was dated 7/5/23. Treatment plan updates were missing for August 2023 through November 2023.
Client # 3 was admitted 11/9/22 and was still an active client at the time of the investigation. Treatment plan updates were missing for June 2023 and August 2023.
Client # 4 was admitted 4/24/23 and still an active client at the time of the investigation. The last treatment plan update was dated 7/20/23. Treatment plan updates were missing for August 2023 through October 2023.
Client # 6 was admitted 3/21/23 and was a current client at the time of the investigation. A treatment plan update was missing for August 2023.
|
Plan of Correction
All staff and supervisors will be trained by 01/30/2024 by the Program Director on the 709.52(b) requirement, including that Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
An internal tracking tool for each chart has been developed to help remind staff of current and upcoming documentation requirements. This includes treatment plan updates. All Plans will be brought up to date by 1/30/2024. The Clinical Supervisor will review the schedule of Treatment Plan updates with the Clinical Staff at minimum on a weekly basis, at the weekly Clinical Team meeting. The Clinical Supervisor will ensure that Treatment Plan updates are occurring according to the Treatment Plan requirements on the weekly schedule, and will collect and review the updated treatment plans prior to their due date and will sign off on the updated plans. The Clinical Supervisor will conduct weekly audits of all charts in order to ensure that timely treatment plan updates are completed for all charts. Any missing documentation will be brought to the attention of the clinician and completed and filed in the client chart within 48 hours. The Clinical Supervisor will review and provide feedback to the therapists for compliance , the Documentation of Treatment Plans and Clinical treatment sessions during regular (e.g. bi-monthly ) individual Supervision meetings with the clinicians. The Clinical Supervisor will present progress with meeting 709.52(a)(2) requirements to the Program Director during regular (e.g. monthly) Supervisor meetings.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that Treatment and rehabilitation plans shall be reviewed and updated as required. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
|
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Based on client chart reviews on November 15, 2023, the facility failed to provide counseling on a regular and scheduled basis 5 of 6 charts reviewed.
Client # 1 was admitted 10/5/22 and was still an active client at the time of the investigation. The treatment plan dated 4/5/23 indicated the client was to receive 1 individual session per week. Individual Session documentation is missing for the months of July, August, September, and October 2023. Also, for the weeks of 4/23, 4/30 and 5/7, 6/11, 6/18, 6/25 and11/5/23.
Client # 2 was admitted on 11/3/22 and discharged 11/8/23. The treatment plan dated 7/5/23 indicated the client was to receive 1 individual session per week. Individual Session documentation is missing for the months of August, September, and October 2023. Also, for the weeks of 7/9, 7/16, 7/23 and 11/5/23.
Client # 3 was admitted 11/9/22 and was still an active client at the time of the investigation. The treatment plans dated 5/11, 7/11, 9/22 and 10/22/23 indicated the client was to receive 1 individual session per week. Individual Session documentation is missing for the months of May, July, and August 2023. Also, for the weeks of 6/11, 6/18, 6/25, 9/3, 9/10, 10/15, 10/22, 10/29, 11/5 and 11/12/23.
Client # 4 was admitted 4/24/23 and was still an active client at the time of the investigation. The treatment plan dated 7/20/23 indicates the client was to receive 1 individual session per week. Individual Session documentation is missing for the month of September 2023. Also, for the weeks of 7/23, 7/30, 8/6, 8/13, 8/20, 8/27, 10/1, 10/22 and 10/29/23.
Client # 6 was admitted 3/21/23 and was a current client at the time of the investigation. Treatment plans dated 4/21, 5/22, 6/22, 7/22, 9/30 and 10/30/23 indicates the client was to receive1 individual session per week. Individual sessions documentation is missing for the months of July, September, and October 2023. Also, for the weeks of 5/7, 5/14, 5/21, 5/28, 6/4, 6/18, 7/30, 8/13, 8/20, 8/27 and 11/5/23.
|
Plan of Correction
All staff and supervisors who are responsible for the provision of counseling services will be trained by the Program Director by 1/30/2024, on the 709.52(d) Regularity of Counseling provided, including that Counseling shall be provided to a client on a regular and scheduled basis.
The Clinical Supervisor will maintain a schedule of weekly and month clinical activities, and will review on a weekly and monthly basis that counseling services are provided in adequate frequencies per individual treatment and rehabilitation plans. The Clinical Supervisor will use reports from the agency Electronic Health Record to ensure that counseling services are provided according to the individual treatment and rehabilitation plans. Provision of counseling services frequencies will be reviewed at every therapist individual staff supervision meeting for every client assigned to the clinician, and at every clinical team meeting for all clients.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that that the project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors who are responsible for the provision of counseling services will be trained on this plan of corrective by 1/30/2024.
|
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
|
Observations
Based on client chart reviews on November 15, 2023, the facility failed to provide a complete client record which is to include an aftercare plan, in 1 of 6 charts reviewed.
Client # 2 was admitted on 11/3/22 and discharged on 11/8/23. An aftercare plan was missing from the chart.
|
Plan of Correction
All staff and supervisors who are responsible for Aftercare planning will be trained on 709.53(a)(9) Client record requirement, including that 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: Aftercare plan, if applicable.
The Clinical Supervisor will maintain a list of active clients and client discharges, and will review on a weekly and monthly basis that Documentation of an aftercare plan is present in the client's clinical chart. Documentation will be reviewed at every therapist individual staff supervision meeting for every client assigned to the clinician, and at every clinical team meeting for all discharged clients.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that follow up information documentation is present in the official client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors who are responsible for aftercare planning with clients will be trained on this plan of corrective by 1/30/2024.
|
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.
|
Observations
Based on client chart reviews on November 15, 2023, the facility failed to provide a complete client record which is to include an discharge summary in 2 of 6 charts reviewed.
Client # 2 was admitted on 11/3/22 and discharged on 11/8/23. A discharge summary was missing from the chart.
Client # 5 was admitted 12/13/22 and discharged 5/30/23. A discharge summary was missing from the chart.
|
Plan of Correction
All staff and supervisors who are responsible for Discharge planning will be trained by the Program Director on the 709.53(a)(10) Client record requirement by 1/30/24, including that 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: Discharge summary.
All required discharge summaries will be filed in the client chart by 1/30/24. The Clinical Supervisor will maintain a list of active clients and client discharges, and will review on a weekly and monthly basis that Documentation of an Discharge Summary is present in the client's clinical chart. Documentation will be reviewed at every therapist individual staff supervision meeting for every client assigned to the clinician, and at every clinical team meeting for all discharged clients. Any missing documentation will be brought to the attention of the clinician and completed within 48 hours.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that discharge summary documentation is present in the official client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors who are responsible for Discharge planning with clients will be trained on this plan of corrective by 1/30/2024. |
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.
|
Observations
Based on client chart reviews on November 15, 2023, the facility failed to provide a complete client record which is to include verification that work done by the client at the facility is an integral part of the treatment and rehabilitation plan in 6 of 6 charts reviewed.
Client # 1 was admitted 10/5/22 and was still an active client at the time of the investigation. According to the Work Therapy Assignment Sheet, each client is assigned a weekly chore. Treatment plans dated 3/3, 4/5 and 5/3 were missing work therapy as a goal.
Client # 2 was admitted on 11/3/22 and discharged 11/8/23. According to the Work Therapy Assignment Sheet, each client is assigned a weekly chore. Treatment plans dated 12/5/22, 6/5/23 and 7/5/23 were missing work therapy as a goal.
Client # 3 was admitted 11/9/22 and was still an active client at the time of the investigation. According to the Work Therapy Assignment Sheet, each client is assigned a weekly chore. Treatment plans dated from 1/12/23 through 10/22/23 were missing work therapy as a goal.
Client # 4 was admitted 4/24/23 and was still an active client at the time of the investigation. According to the Work Therapy Assignment Sheet, each client is assigned a weekly chore. The treatment plan dated 7/20/23 was missing work therapy as a goal.
Client # 5 was admitted 12/13/22 and discharged 5/30/23. According to the Work Therapy Assignment Sheet, each client is assigned a weekly chore. The treatment plans dated from 1/10/23 through 5/11/23 were missing work therapy as a goal.
Client # 6 was admitted 3/21/23 and was still an active client at the time of the investigation. According to the Work Therapy Assignment Sheet, each client is assigned a weekly chore. The treatment plans dated from 4/21/23 through 10/30/23 were missing work therapy as a goal.
|
Plan of Correction
All staff and supervisors who are responsible for Treatment planning will be trained by the Program Director on the 709.53(a)(12) Client record requirement, including that 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, Verification that work done by the client at the project is an integral part of his treatment and
rehabilitation plan.
The Clinical Supervisor will review Treatment Plans prior to signing and filing and ensure that any work therapy engaged by the client is documented in their Treatment Plans. Treatment Plan Documentation will be reviewed at every therapist individual staff supervision meeting for every client assigned to the clinician, and at every clinical team meeting for all clients.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that work therapy documentation is present in the Treatment Plans for clients engaging in work treatment. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors who are responsible for Treatment planning and work therapy with clients will be trained on this plan of corrective by 1/30/2024. |
709.53(b) LICENSURE Standardized Forms
709.53. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
|
Observations
Based on client chart reviews on November 15, 2023, the facility failed to maintain client records on standardized forms in 1 of 6 client charts reviewed.
Client # 3 was admitted 11/9/22 and was still an active client at the time of the investigation. The individual sessions dated 9/17, 9/28, 10/5 and 10/12/23 were not documented on the facility ' s standardized progress note form. These notes were missing a time in and out, a therapist ' s name and a therapist ' s dated signature.
|
Plan of Correction
All staff and supervisors who are responsible for documenting in the client chart will be trained by the Program Director on the 709.53(b) Client record requirement, including that the
project shall develop and maintain client records on standardized project client record forms.
The Clinical Supervisor will review clinical documentation at every therapist individual staff supervision meeting for every client assigned to the clinician, and at every clinical team meeting for all clients. The Clinical Supervisor will review that documentation is being completed on the facility's standardized client record forms and that the forms are completed in their entirety, including signatures and dates. Client form templates are kept in the agency Electronic Health Record , and in an accessible shared computer Network Drive folder location.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that work documentation is present in the clinical chart using standardized project client forms and that the forms are completed in their entirety, including signatures and dates. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors who are responsible for clinical documentation will be trained on this plan of corrective by 1/30/2024. |