INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24, 2024 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation ensuring that written individual training plans were developed annually with input from both the employee and the supervisor in two of two applicable personnel records reviewed.
Employee # 1 was hired as the project/facility director on June 28, 2017. The 2024 individual training plan was signed by the employee, but there was no additional documentation that the plan was developed with input from the supervisor.
Employee # 2 was hired as a clinical supervisor on February 12, 2024. The 2024 individual training plan was signed by the employee, but there was no additional documentation that the plan was developed with input from the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will conduct a review of existing Staff Training Plan documentation by 9/15/2024. All active staff at IHW without a fully completed Individual Training Plan on file at IHW will complete a new Individualized Training Plan with input from both the employee and supervisor by 9/30/2024. A copy of the completed staff individual training plan with input from both the staff member and supervisor will be kept on file in the staff members training files.
During staff orientation, within 30 days of hire, all new staff will complete the initial IHW Individual Staff Training Plan with their assigned supervisor. Every year, during the month of January, all existing staff will complete the IHW Individual Staff Training Plan annual update Plan with their assigned supervisor. Both staff and supervisor, prior to signing and dating the initial or annual update Staff Training Plans, will individualize the Staff Training Plan by adding information (e.g. goals, comments) specific to that staff member. A copy will be offered to the staff member, and the original will be reviewed by the Program Director for completeness prior to being placed in the staff's personnel file.
All staff and supervisors will be trained by the Program Director on the requirements of 704.11(b)(1) and on this plan of correction, and the plan will be fully implemented by 9/30/2024. A copy of staff training completion will be kept on file in the staff members training files.
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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
Based on a physical plant inspection conducted on July 24, 2024 between 12:00 PM and 1:00 PM, the facility failed to keep the facility in good repair at all times for the safety and well-being of residents, employees, and visitors.
At the time of the inspection, there were window screens that were either ripped, bent, or loose in room #'s 201A, 204A, 304A, 304B as well as in the family overflow suite, which is between room #'s 306A and 306B.
This is a repeat citation from the February 6, 2024 provisional license follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors responsible for Building exterior and grounds will be trained by the Program Director on the 705.2 (2) Building exterior and grounds regulation requirement and on this Plan of Correction by 9/30/2024. The training will include the requirement that the residential facility shall 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, and that the exterior of the building and the building grounds or yard shall be free of hazards. Training will be completed by 9/30/2024. A copy of the training completion and staff participating will be kept on file in the staff members training files.
The Facility Manager will submit a request to the PHMC Facilities Department to replace damaged window screens in room #'s 201A, 204A, 304A, 304B, and 306A/306B family overflow suite. The request will be submitted by the facilities manager by 8/31/2024. The Facility Manager will report to the Program Director on the progress of the facilities request , that it is completed according to the 705.2 (2) Building exterior and grounds regulation requirement. Damaged screens will be repaired or replaced by 9/30/2024. A copy of the facilities ticket request and a copy of the completion report will be kept on file in the PHMC facilities database.
During regular (e.g. daily) building exterior and grounds checks, The Facility Manager will review that building exterior and grounds are according to 705.2 (2) Building exterior and grounds regulatory requirements. The IHW facility manager will report any issues to the Program Director for internal Plan of Correction, and will create and send any correction issues to PHMC facilities department by email or phone when appropriate. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
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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 conducted on July 24, 2024 between 12:30 PM and 1:00 PM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
At the time of the inspection, the bathroom, in room 203 B, had a broken toilet that did not flush.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Please note, the broken flush toilet in room 203B was repaired on the same day as the licensing inspection visit 7/24/24 by the facilities department.
All staff and supervisors responsible for Building exterior and grounds will be trained by the Program Director on the 705.6 (7) Licensure Bathrooms regulation requirement and on this Plan of Correction. The training will include the requirement that the residential facility shall Maintain each bathroom in a functional, clean and sanitary manner at all times. Training will be completed by 9/30/2024. A copy of the training completion and staff participating will be kept on file in the staff members training files.
Immediately upon discovery, the Facility Manager will submit requests to the PHMC Facilities Department to repair any damaged or inoperable bathroom fixtures (toilets, sinks, showers, etc.). The Facility Manager will report to the Program Director on the progress of the facilities requests , that they are completed according to the 705.6 (7) Licensure Bathrooms regulation requirements. A copy of the facilities ticket requests and a copy of the completion report will be kept on file in the PHMC facilities database.
During regular (e.g. daily) building exterior and grounds inspections, staff conducting the facility and ground inspections will report to The Facility Manager that bathrooms are functional , clean and sanitary at all times according to 705.6 (7) Licensure Bathrooms regulation requirements. The IHW facility manager will report any functionality issues to the Program Director for internal Plan of Correction, and will create and send any functionality correction issues to PHMC facilities department by email or phone when appropriate. Copies of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to ensure the project director annually, prepared, updated, and signed the written manual delineating the project policies and procedures.
The facility was unable to provide documentation that the manual was updated and signed by the project director on an annual basis at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will review and sign the written manual by 8/30/2024.
Minimally every year, during the month of January, per the facility calendar, the Project Director will review and sign the written manual delineating project policies and procedures. The signature page will be kept in the front of the original policy and procedure manual in the Project Director's office on site at the IHW facility.
All staff and supervisors responsible for policy manual preparation, annual update, and and signing of the written manual delineating project policies and procedures will be trained by the Program Director on the 709.23 Project director requirement and on this plan of corrective and the plan fully implemented by 9/30/2024.
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of one applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client # 6 was admitted on May 24, 2024 and was discharged against medical advice on June 24, 2024. There was no documentation in the record that the emergency contact was notified of the client's discharge against medical advice.
This is a repeat citation from the February 6, 2024 provisional license follow-up inspection and the August 3, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 9/30/2024, all staff and supervisors responsible for discharge notifications will be trained by the Project Director in the requirements of 709.24(a)(3) treatment/ rehabilitation management, and DDAP LICENSING ALERT 02-21, 9/1/2021; and DDAP Informational Bulletin 01-19; and PA Act 41 of 2021, 71 P.S. § 613.1(8.1), 8/29/2021 and IHW's "AMA/ AFA Notifications" policy.
The Program Director will train all staff responsible for implementing the policy (e.g. therapists, admissions coordinator, case manager, residential assistants, clinical director, nurses). A record of the training course will be kept in the staff training records.
During intake, the staff conducting the intake/ admission for each new client will collect Emergency Contact information and place the emergency contact's information in the official client record.
When an AMA/AFA occurs, the Clinical Director will ensure that staff are completing emergency contact notifications as follows:
IHW's drug and alcohol residential treatment facility Therapist or designee will immediately notify an emergency contact if a client leaves the facility against medical advice (AMA)/ against facility advice (AFA), provided the client has not revoked the on file consent to notify the emergency contact. Notification shall occur immediately and in no event later than 12 hours of a patient leaving against medical advice. IHW must notify the emergency contact by a method consented to by the patient on the Emergency Contact Release of Information (ROI). The staff conducting the intake/admission with the client will ensure that an Emergency Contact ROI is completed and signed by the client and/or legal guardian and a witness at intake and kept in the client's official file on site at the residential facility. IHW must attempt to notify the emergency contact at least once upon knowledge of a client's leaving the facility AMA/AFA, and document the attempt in the official client record as a Service Note.
The Notice of Privacy Practices, which includes details of required notifications, and this policy, is shared by IHW with the client and/or legal guardian, during the intake admission by the Admissions Coordinator.
IHW will not make notifications when Interim House Inc has knowledge of or reason to know of allegations of domestic abuse perpetrated upon the client by the client's designated emergency contact.
During regular (e.g. biannually) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, and that ROIs are in use during communications with outside parties. The PHMC Compliance Department will monitor that emergency notifications are made and documented according to the AMA/AFA Notifications Policy and Procedure. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained on this plan of correction by the Program Director and the plan fully implemented by 9/30/2024.
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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 on consent to release information forms in five of seven client records reviewed.
Client # 1 was admitted on May 30, 2024 and was still active at the time of the inspection. There was a release of information form signed by the client on May 30, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made and only stated "insurance carrier".
Client # 2 was admitted on April 16, 2024 and was still active at the time of the inspection. There was a release of information form signed by the client on April 16, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made and only stated "insurance carrier".
Client # 3 was admitted on June 5, 2024 and was still active at the time of the inspection. There was a release of information form signed by the client on June 5, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made and only stated "insurance carrier".
Client # 6 was admitted on May 24, 2024 and was discharged on June 24, 2024. There was a release of information form signed by the client on May 24, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made and only stated "insurance carrier".
Client # 7 was admitted on February 26, 2024 and was discharged on June 7, 2024. There was a release of information form signed by the client on February 26, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made and only stated "insurance carrier".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will conduct an internal review of all active client file documentation of Consent for the Release of Information (ROI), including that documentation includes 709.28 (c) (1) required information: in writing and include, but not be limited to: (1) Name of the person, agency or organization to whom disclosure is made. Errors and incomplete documentation of Consent for ROI discovered during the internal review will be amended, signed, and dated, with consent from the client, by 9/30/2024.
Prior to disclosure of information, all staff will be responsible to obtain an informed and voluntary consent for Release of Information (ROI) from the client, documented in the official client record per PA Code 709.28 (c) Confidentiality requirements.
During the intake admission process, Consent for Release of Information will be discussed and completed for Insurers, Primary Care Physicians (PCP), Dentists, Medical Specialists , treatment providers, and any other involved disclosure parties. Prior to disclosure of information, staff will ensure that there is a complete and valid/ signed ROI on file in the client record for the 3rd party. If not, then the staff member will discuss the disclosure with the client, and obtain written documented consent prior to making the disclosure. Documentation of the consent and the disclosure will be placed in the official client record.
As part of the Individualized Staff Training Plan development, within 30 days of hire, supervisors will instruct every staff member assigned to them to complete a DDAP Approved Confidentiality Training Course within 365 days of hire, which includes information about obtaining Consent for Release of Information.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that complete and valid ROI documentation is present in the official client record, and that ROIs are in use during communications with outside parties. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors will be trained on the requirements of 709.28 (c) (1) Licensure Confidentiality and on this plan of corrective by the Program Director and the plan will be fully implemented by 9/30/2024.
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709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a physical examination during the intake and admission process in three of seven client records reviewed.
Client #1 was admitted on May 30, 2024 and was active at the time of inspection. There was no documentation of a physical examination in the record.
Client #4 was admitted on May 6, 2024 and was discharged on June 20, 2024. There was no documentation of a physical examination in the record.
Client #6 was admitted on May 24, 2024 and was discharged on June 24, 2024. There was no documentation of a physical examination in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will conduct an internal review of all active client file documentation for the presence of documentation of a Physical Examination, according to the requirements of 709.51(b)(5). Missing Physical Examination documentation will be requested from the client's physicians with a valid Release of Information (ROI) and obtained and placed in the client files by 9/30/2024.
During the intake admission process, Consent for Release of Information will be discussed and completed for Primary Care Physicians (PCP). Clients without PCP will be referred for PCP providers. Clients will be assisted to schedule and complete a PCP physical examination appointment as needed according to IHW' physical examination procedures. Upon completion of physical examinations, the nurse will use the valid ROI on file in the official client record to request a copy of the documentation of the physical examination from the PCP for the client record, and will file the copy of the request and of the physical examination documentation into the client record. The nurse will keep track that every client has a scheduled and completed physical examination appointment, that documentation of the physical examination is requested from the PCP and received and filed in the client file. The nurse will report to the Program Director on the status of the Physical examinations and documentation during regular (e.g. monthly) nurse supervision sessions.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that documentation of a physical examination 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 responsible for physical examination completion and documentation will be trained on the requirements of 709.51(b)(5) and on this plan of correction by the Program Director , and the process fully implemented by 9/30/2024.
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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 review of client records and the policy and procedure manual, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to follow the project's written procedures for the management of treatment/rehabilitation services was submitted and approved by the Department for the August 3, 2023 annual licensing inspection and the February 6, 2024 provisional license follow-up inspection. Failing to follow the project's written procedures for the management of treatment/rehabilitation services was again found to be a deficiency in the July 24, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors responsible for implementing Department approved plans of correction will be trained by the Program Director on the requirements of 709.17(a)(3) by 9/30/2024. Staff participation in this training will be kept in staff training files.
Staff responsible for implementing Department approved plans of correction will report plans of correction implementation status to their Supervisors during regular (e.g. monthly) Supervision meetings. Compliance with meeting plans of correction implementation will be documented on Individual Staff Supervision Notes.
Supervisors will report plans of correction implementation status to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting plans of correction implementation will be documented on The Supervisors' Individual Staff Supervision Notes.
The Project Director will report plan of correction implementation status to the PHMC Managing Director of Addiction Services Division during regular (e.g. monthly) Supervision meetings. Compliance with the Program's meeting plans of correction will be documented on The Program Director's Individual Staff Supervision Notes.
During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that plans of correction approved by the Department are being implemented according to 709.17(a)(3). The Compliance Department will report any findings to the Program Director and Managing Director of Addiction Services for internal Plan of Correction.
All staff and supervisors will be trained on the requirements of 709.17(a)(3) and on this plan of correction by the Program Director, and this plan fully implemented by 9/30/2024.
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