INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2016 by staff from the Division of Drug and Alcohol 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.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Base on a review of the Staffing Requirements Facility Summary Report and staff interview, the facility failed to ensure that employee #6 completed the mandatory HIV/AIDS training within the required timeframe.
Employee #6 is a residential assistance and was hired March 6, 2013. HIV/AIDS training was due to be completed no later than March 6, 2015. Facility indicated on the Staffing Requirements Facility Summary Report that employment #6 did not received the require HIV training. After interviewing the staff at the facility, the facility stated employee #6 did not receive the HIV training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of the Staffing Requirements Facility Summary Report and staff interview, IHW failed to ensure that all employees completed the mandatory HIV/AIDS training within the required timeframe.
HIV/AIDS trainings will be completed by all staff within the designated timeframe from their hire date. Supervisors will complete training assessment plans for newly hired staff within first week of employment and annual training plans yearly to ensure all required training is completed. The Administrative Assistant will review and track all training plans quarterly to ensure trainings are completed. |
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.
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Observations
The findings include:
A physical plant inspection was conducted on July 8, 2016. The facility failed to keep the grounds safe, and sanitary and in good repair at all times. Client mattressess were torned in multiple rooms on the 2nd and 3rd floor.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Based on a physical plant inspection, IHW failed to keep the grounds safe, and sanitary and in good repair. Client mattresses were torn in several rooms on the 2nd & 3rd floors.
The Facility Manager will inspect all client mattresses for wear and tear. All mattresses found to not be in good repair will be replaced. All client mattresses will be inspected and monitored weekly by Residential Assistants. Conditions of mattresses will be tracked on the weekly building inspection report and reviewed by the Facility Manager. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
The findings include:
A physical plant inspection was conducted on July 8, 2016. The facility failed to keep the furniture in good repair at all times.
The furniture was not in good repair as rips were observed on some of the couches on the resident's floors.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Based on a physical plant inspection, IHW failed to keep the furniture in good repair at all times. Couches observed during the inspection were ripped and not in good repair.
The Facility Manager will inspect all furniture for rips, wear & tear. All couches found ripped will be replaced. Residential Assistants will inspect and monitor all furniture and provide weekly reports to the Facility Manager to ensure all furniture is in good repair. |
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
The findings include:
Six client records were reviewed on July 8, 2016. All were reviewed for informed and voluntary consent forms. The facility failed to document informed and voluntary consents in client record, #5.
Client #5 - Consent to release dated April 13, 2016 for the client's funding source failed to have the specific information disclosed documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In charts audited, IHW staff failed to correctly document informed and voluntary consent in 1 of 6 charts audited. The consent to release failed to have the specific information disclosed documented.
IHW Clinical Director will hold a staff training to review 709.28 regulations as it pertains to release of information. Trainings will be documented by signature of attendance sheets. All current releases will be reviewed and updated to meet this regulation. Total Quality Management will conduct chart audits quarterly to ensure releases of information are completed correctly |
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
Six client records were reviewed on July 8, 2016 for informed and voluntary consent forms and progress notes. The facility failed to document if the client was offered a copy of the informed and voluntary consent forms in record, #4.
Client #4 - There was no indication on the form or on a progress note as to whether the client accepted or refused of a copy of the consent to release information form dated February 19, 2016 for the family member.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In 1 of 6 charts audited, IHW staff failed to document if the client was offered a copy of the informed and voluntary consent form.
IHW's Clinical Director will hold a staff training to review 709.28 regulations as it pertains to informed and voluntary consent forms. Trainings will be documented by signature of attendance sheets. All current informed and voluntary consent forms will be reviewed and updated to meet this regulation. Total Quality Management will conduct quarterly chart audits to ensure this regulation is met. |