INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 12, 2021 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:
|
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, the facility failed to 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. On August 12, 2021 at approximately 11:00 AM, a group room, located in the basement area of the facility, had an active water leak. Facility staff reported that the water was infiltrating the building from a recent rainstorm.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/16/2021 IHW Facility Manager work closely with PHMC Facility to assess the water leak in basement. An outside contractor was call in to assess the water leak in the basement on 8/24/2021. The leak in basement wall needs repair, and the process is as follow: old dry wall will be removed, the wall will be painted with dry lock paint, new dry wall and paint will complete the project. PHMC Facility will report to IHW Facility Manager and Program Director when basement wall is complete. IHW Facility Manager will do a walk through after job is complete. IHW Facility Manager will monitor repair and provide Program Director an update on facility repairs in Facility Manager monthly report. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that each bedroom had a bed with a fire-retardant mattress that was in good repair. On August 12, 2021 at approximately 10:15 AM, there was a mattress in room 301B that was ripped and torn at the seam.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
New mattress was ordered on 8/24/2021 and will be placed on bed by 9/1/2021. Facility Manager will monitor and track all mattress to ensure safety and good repair. Residential Assistant who are sign to client's room will inspect and monitor mattress. If a mattress needs to be replaced, a repair slip will be given to the facility manager and maintenance assistant for mattress to be replaced. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
Based on a physical plant inspection, the facility failed to ventilate each toilet and washroom by an exhaust fan or a window. On August 12, 2021 at approximately 10:15 AM, the bathroom exhaust fans in rooms 201B and 305B were not operable and there were no windows in the bathrooms.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
IHW Facility Manager will work closely with PHMC Facility to assess or repair the exhaust fan in room 201B and 305B. PHMC Facility assess the exhaust fan 8/19/2021. Fan needs to be repair, and the repair will be completed by 9/2/2021. Going forward the Residential Assistant who are assigned the client's room will inspect and monitor room for any repairs. A repair slip will be given to the IHW Facility Manager or to PHMC Facility. IHW Facility Manager will assign IHW Facility Maintenance assistant or PHMC facility to complete the repair. IHW Maintenance Assistant or PHMC Facility Maintenance Assistant will report to IHW Facility Manager when repairs are completed. IHW Facility Manager will monitor all repairs and provide Program Director an update on facility repairs in Facility Manager monthly report. |
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.
|
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 12, 2021 at approximately 10:20 AM, the bathroom in room 304 B had a broken light cover, exposing sharp edges.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The maintenance assistance repaired the broken light cover on 8/ 12/2021 in bathroom of 304B. Maintenance assistant will inspect all bathroom to ensure all light cover or not broken. Any light cover in disrepair will be replaced. Maintenance assistant will monitor and track all broken light covers to ensure safety. Maintenance will report any broken light covers in his daily report to Facility Manager. During weekly household management class with the clients, facility manager will encourage clients to report and complete a repair slip with repair is needed in their room. Residential assistant will monitor client's room daily for repair during their daily rounds. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
|
Observations
Based on a physical plant inspection, the facility failed to secure hard copy client records within locked storage containers. On August 12, 2021 at approximately 11:00 AM, there were unlocked shredding bins, located in the basement of the facility, that had paper client records in them.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
IHW Program Director met with Administrative Assistant on 8/13/2021 an provide a training as it pertains to storage clients records in locked secure area. Clients records that is placed in a shredding bin will be lock in the shredding bins and storage in the file room until shredding company is able to pick up records. |
709.28 (c) 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.
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed.
Client # 2 was admitted on February 10, 2021 and was discharged on May 28, 2021. There was evidence of disclosures to a government agency on March 23, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client # 3 was admitted on March 1, 2021 and was discharged on July 15, 2021. There was evidence of a disclosure to a government agency on March 23, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
IHW Clinical Director and Program Director held a staff training on confidentiality 8/27/2021 as it pertains to releasing information to an agency before client signs the consent form. Training was documented by signature of attendance sheets. All current release will be reviewed and updated to meet regulation. Clinical Director will review clinical chart weekly to ensure consent forms are completed correctly and a client as signed the consent form to release information before the information is release. All consent forms will be address immediately after chart audit by Clinical Director. Clinical Director will also address any concerns with staff as it contains to consent forms during weekly supervision and on-going trainings as necessary. |
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.
|
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 a consent to release information form in one of seven client records reviewed.
Client # 2 was admitted on February 10, 2021 and was discharged on May 28, 2021. The release of information form to an insurance carrier was signed and dated by the client and witness on February 10, 2021; however, the form failed to document the name of the person, agency or organization to whom the disclosure would be made to.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
IHW Clinical Director and Program Director held a staff training on confidentiality 8/27/2021 as it pertains to release of information, person, agency, or organization. Training was documented by signature of attendance sheets. All current release will be reviewed and updated to meet regulation. Clinical Director will review clinical chart weekly to ensure consent forms are completed correctly. Clinical Director will ensure that consent form identify the person, agency or organization is identified. All consent forms will be address immediately after chart audit by Clinical Director. Clinical Director will address any concerns with staff as it contains to consent forms during weekly supervision and on-going trainings as necessary. |
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.
|
Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information forms in one of seven client records reviewed.
Client # 5 was admitted on June 11, 2021 and was still active at the time of the inspection. The release of information forms to the funding sources, a government agency, and another treatment provider were signed and dated by the client and witness on June 11, 2021; however, none of the forms documented the purposes of the disclosures.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
IHW Clinical Director and Program Director held a staff training on confidentiality 8/27/2021 as it pertains to releasing of information. The training focus on making sure the purposes of the disclosure is stated. Training was documented by signature of attendance sheets. All current release will be reviewed and updated to meet regulation. Clinical Director will conduct weekly chart audit to ensure that consent forms are completed correctly, and it identify the purposes of the disclosures. All consent forms will be address immediately after chart audit by Clinical Director. Clinical Director will address any concerns with staff as it contains to consent forms during weekly supervision and on-going trainings as necessary. |
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
Based on a review of the facility's February 2021 through July 2021 unusual incident 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 the following dates: April 3, 2021, April 16, 2021, May 17, 2021, May 28, 2021, July 6, 2021, July 15, 2021, and July 21, 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
PHMC has a system in place in which all unusual incidents are reported to PHMC data base, and the facility (IHW) must send the report to DDAP. IHW Clinical Director and Program Director held a staff training on 8/27/2021 regarding unusual incident reporting to ensure that all staff know unusual incidents reports should be sent to DDAP within twenty-four hours of the incident. When an Unusual incident is reported, the staff person who is completing the report will complete the report in PHMC date base, print the report, fax the report to DDAP, provide clinical director verification of incident report being sent by fax. The unusual incident report and fax confirmation will be given to clinical director and file for review. All unusual incident reported identify in deficiency report was sent via fax on 8/27/2021 to DDAP. |