INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 2013 through July 9, 2013 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.
The following deficiencies were identified during this inspection.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of administrative documentation, the project failed to appropriately identify the person responsible for the overall management of the Project.
Findings:
Employee # 1 was identified as the Project Director on the Staffing Requirements Facility Summary Report; however, employee # 1 is not responsible for the overall management of the Project.
Employee # 1 was hired by the project 8/13/93, and was later appointed as the Facility Director by the Project on 10/28/04. However, there was no documentation of a request or approval for employee # 1 to be identified as the Project Director since she is not responsible for the overall management of the multi-service organization.
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Plan of Correction
The CEO will write a letter to the State requesting an exception to the regulation which will allow the facility director to be the Project Director. In the event that the request is not approved, the CEO will be named Project Director. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observation during a physical plant inspection, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom.
The findings include:
A physical plant inspection was conducted on July 9, 2013 at approximately 2 PM.
The facility failed to provide either individual paper towels or a mechanical dryer in one out of three of the children's bathrooms.
The Facility Manager confirmed the findings.
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Plan of Correction
Effective immediately, the facility maintenance person will be responsible for ensuring that all bathrooms are properly equipped with bathroom tissue and paper towels at all times. This will be monitored by the facility manager on a daily basis. The program director will provide additional supervision and ensure that 705.6 standard is met via visual inspection as well as weekly facility staff supervision. |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on observation during a physical plant inspection, the facility failed to provide toilet paper at each toilet at all times.
The findings include:
A physical plant inspection was conducted on July 9, 2013 at approximately 2 PM.
The facility failed to provide toilet paper in one out of two of the children's bathrooms.
The Facility Manager confirmed the findings.
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Plan of Correction
Effective immediately, the facility maintenance person will be responsible for ensuring that all bathrooms are properly equipped with bathroom tissue and paper towels at all times. This will be monitored by the facility manager on a daily basis. The program director will provide additional supervision and ensure that 705.6 standard is met via visual inspection as well as weekly childcare supervision. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on observation during a physical plant inspection, and an interview with the facility manager, the facility failed to keep frozen food at or below 0 F degrees.
The findings include:
A physical plant inspection was conducted on July 9, 2013 at approximately 2 PM.
The facility's freezer had a temperature greater than 0 F degrees. The thermometer in the freezer and on the outside freezer door read a temperature of 20 F degrees.
In addition, the posted temperature log for the month of June 2013, indicated that the freezer measured above 0 F degrees for the entire month of June 2013. Based on the temperature log, the average temperature for the month of June 2013 was 10 F.
The facility manager confirmed at the time of the physical plant inspection that the freezers temperature exceeded 0 F.
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Plan of Correction
IHW facility manager will ensure that all frozen food temperature is kept at or below zero degrees at all times. The freezer was serviced on 7/10/13 Urie Associates and found to be in good working order. The thermometer read zero at the time of service. Urie also instructed the facility manager to read the temperature from the internal thermometer. Before this inspection, IHW was reading temperatures from the outside thermometer located on the outside of the freezer and sensitive to the room air. The facility freezer will be inspected quarterly to ensure it is in good working order. The freezer thermometer will continue to be checked daily to ensure they are also operable and reading accurately.
The facility manager and program director will hold a residential assistant training to inform them of the new procedures and to ensure 709.7 standards are adhered to. The training will occur 8/23/2013
The Program Director will monitor compliance on a monthly basis via supervision.
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
On July 8, 2013, the facility's fire drill log was reviewed covering the period from August 2012 through June 2013.
The facility failed to set off a fire alarm or smoke detector during two of ten fire drills conducted, specifically on 4/21/13 and 6/29/13. The fire drill log documented "loud voices hurricane."
The Facility Manager and Project Director confirmed that neither the fire alarm nor smoke detector was set off during the the months of April 2013 and June 2013.
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Plan of Correction
IHW's facility manager will ensure that the fire and/or smoke alarms are pulled during every fire drill. This will include all shelter in place drills. IHW will hold unannounced fire drills on a monthly during sleeping and waking hours. All drills will have a log indicating, date time, evacuation time, exit route used and number of persons in the facility. The program will continue to identify different evacuation routes as outlined by the fire department. The program director and facility manager will hold a staff and resident in-service to address this standard. Training will occur on 9/6/13.
Compliance will be monitored by program director on a monthly basis.
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705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on observation during a physical plant inspection, the facility failed to maintain protective caps over each electrical outlet.
The findings include:
A physical plant inspection was conducted on July 9, 2013 at approximately 2:00 PM.
The facility failed to maintain protective caps over each electrical outlet. An uncovered electrical outlet was observed in one of three daycare rooms. The exposed electrical outlet was behind a table where children were sitting. In addition, 5 bedrooms, bedroom # 301 A, 302 A, 302 B, 304 and 306, were missing protective caps over some of the electrical outlets. In particular, one of the exposed outlets was directly behind a baby's crib.
The Facility Manager confirmed the findings.
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Plan of Correction
IHW facility manager will be responsible for ensuring that the entire building has protective caps on all electrical outlets. The maintenance person, residential assistants and teachers will have an adequate supply of protective caps to replace as needed. The facility manager and childcare supervisor will hold training with IHW families to address the importance of childcare covers. This training will take place 9/6/13 at 3:30pm.
Program Director and Facility Manager will monitor compliance on a weekly basis.
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2012 annual report, the governing body failed to make available to the public an annual report which included a financial statement of income and expenses.
The findings include:
The 2012 annual report was reviewed on July 8, 2013. The facility made the 2012 annual report available to the public on June 7, 2013. However, the 2012 annual report did not include a financial statement of income and expenses.
The presented report stated "Copies of Interim House West's financial statements are available upon request."
The Project Director did not dispute the findings.
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Plan of Correction
IHW will prepare an annual report which will include activities; accomplishments, financial statement of income and expenses, names of officers, directors, and board members. The annual report will be made available to the public via newspaper notice.
The Program Director will be preparing the report on an annual basis. Compliance will be monitored by BHS's deputy director on a monthly basis.
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709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the 2012 annual report, the governing body failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders.
The findings include:
The 2012 annual report was reviewed on July 8, 2013. The facility made the 2012 annual report available to the public on June 7, 2013. However, the 2012 annual report did not include a statement disclosing the names of officers, directors and principal shareholders.
The presented report stated "A list of PHMC board members and officers are attached at the end of this report."
The Project Director did not dispute the findings.
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Plan of Correction
IHW will prepare an annual report which will include activities; accomplishments, financial statement of income and expenses, names of officers, directors and a list of board members and principal shareholders. The annual report will be made available to the public via newspaper notice and internet.
The Program Director will be preparing the report on an annual basis. Compliance will be monitored by BHS's deputy director on a monthly basis.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain and comply with an informed and voluntary consent for the disclosure of information in client record # 4.
The findings include:
Eight client records requiring documentation of an informed and voluntary consent were reviewed on July 8, 2013 and July 9, 2013.
The facility failed to obtain a valid informed and voluntary consent for the disclosure of client information in client record # 4. In addition, the facility disclosed to a government agency information which exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (b).
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
On 4/13/13 the facility released to a government agency client # 4's psychiatric evaluation. The information contained in the psychiatric evaluation exceeded the limitations imposed at 4 Pa. Code 255.5 as it revealed the client's legal history, trauma factors, mental status exam, developmental history, medical history, substance abuse history, substances abused, history of present illness, medical illness, surgeries, and medication.
The clinical supervisor did not dispute the findings.
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Plan of Correction
The clinical director will provide a mandatory staff training to address, client privacy, voluntary consents, release of information and 255.5. This training will be held on 9/13/13. All consents will be in writing and will include:(1) Name of person, agency or organization to whom disclosure is made(2) specific information released(3) purpose of disclosure(4) dated signature of client (5) dated signature of witness(6) expiration date of consent.
Additionally, the clinical director and TQM team will perform monthly chart to ensure voluntary release of information forms are obtained as needed, completed accurately and do not exceed 255.5.
Program director will monitor compliance via monthly supervision and chart audit reports.
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