INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection and a complaint investigation conducted on February 6, 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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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 February 6, 2024, between 10:00 AM and 10:45 AM, the facility failed to keep the facility in good repair at all times for the safety and well-being of residents, employees, and visitors.
There were window screens missing from operable windows in room #'s 201B, 301B, 305A, 305B, and 306B. Additionally, there were screens that were ripped and had holes in them in room #'s 201A, 302A, and the family overflow suite between room #'s 304A and 304B.
This finding was 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. 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 3/31/2024. A copy of the training completion and staff participating will be kept on file in the Program Director's Office.
The Facility Manager will submit a request to the PHMC Facilities Department to replace missing window screens in room #'s 201B, 301B, 305A, 305B, and 306B, and damaged window screens in room #'s 201A, 302A, and in the family overflow suite between room #'s 304A and 304B. The request will be submitted by the facilities manager by 3/15/2024. 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. Missing or damaged screens will be replaced by 4/15/2024. A copy of the facilities ticket request and a copy of the completion report will be kept on file in the Program Director's office.
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 Program Director's office.
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705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection conducted on February 6, 2024, between 10:00 AM and 10:45 AM, the facility failed to ensure that all bunk beds were equipped with securely attached railings on each side and open end of the bunk.
The family overflow suites for room #'s 202 A/B, 203 A/B, 204 A/B, 205 A/B, 301 A/B, 302 A/B, 303 A/B, 304 A/B had bunk beds with a mesh bed rail that were not securely attached to the bed. Also, there were large open areas on both sides of the installed bed rails on all the bunk beds in the noted rooms.
Additionally, the family overflow suites for room #'s 305 A/B and 306 A/B had bunk beds with no bed rails on the sides of the beds, leaving the entire side of the bed open.
This is a repeat citation from 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
All staff and supervisors responsible for oversight of client sleeping accommodations will be trained by the Program Director on 705.5 (b) Sleeping accommodations. The training will include the requirement that all bunk beds are equipped with securely attached railings on each side and open end of the bunk. The training will also include the requirement that staff follow the plans of correction as approved by The Department. Training will be completed by 3/31/2024. A copy of the training completion and staff participating will be kept on file in the Program Director's Office.
New Bunk beds were selected and installation was completed on 2/12/2024. There was a delay in installation due to an unforeseen issue with the mattresses fitting on the new bunk beds. All the new bunk beds are equipped with securely attached railings on each side and open end of the bunk. New Bunk beds and new mattresses were installed in the family overflow suites for room #'s 201 A/B, 202 A/B, 203 A/B, 204 A/B, 205 A/B, 301 A/B, 302 A/B, 303 A/B, 304 A/B, 305 A/B and 306 A/B.
During regular (e.g. daily) room checks, Resident Assistants will review that sleeping accommodation are according to 705.5 sleeping accommodation regulatory requirements and will provide a written report daily to the IHW Facility Manager. 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 when appropriate.
During regular (e.g. monthly) Director Supervision Meetings, The Program Director will report to the Managing Director of Addiction Services that plans of correction are being completed as approved by The Department. |
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 two of three applicable client records reviewed.
The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within thirty days of admission.
Client # 1 was admitted on December 19, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than January 19, 2024; however, the plan was completed on January 23, 2024.
Client # 3 was admitted on November 18, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than December 8; 2023; however, the plan was completed on January 23, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors responsible for creation of individual treatment plans will be trained by the Program Director on the 709.24 (a) (3) Treatment/rehabilitation management regulation requirement, and the project's relevant policies and procedures. The training will include the requirement to follow the project's written procedures for the management of treatment/rehabilitation services ; and specifically the project's policy and procedure that states the individual treatment and rehabilitation plan is to be completed within thirty days of admission. Training will be completed by 3/31/2024. A copy of the training completion and staff participating will be kept on file in the Program Director's Office.
The Clinical Director will review Individual Treatment Plans to ensure that they are completed according to the project's policy, within 30 days of admission. The Clinical Director will track the completion of due and coming due Individual Treatment and Rehabilitation Plans and will review the tracking at least weekly during Clinical Team meetings with all the clinicians, and during individual staff supervision meetings with each of the clinicians for their assigned caseloads. The Clinical Director will report at least monthly to the Program Director on Individual Treatment and Rehabilitation Plans completions , that they are done according to the project's written procedures for the management of treatment/rehabilitation services.
During regular (e.g. biannual) client file reviews, The PHMC Compliance Department will monitor that individual treatment and rehabilitation plans are completed within thirty days of admission according to the project's written procedures for the management of treatment/rehabilitation services. The Compliance Department will report any findings to the Program Director for internal Plan of Correction. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, which is to include the reason for termination, in one of one applicable client records reviewed.
Client # 5 was admitted on July 13, 2023 and was administratively discharged on October 20, 2023. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors responsible for client Notifications of termination will be trained by the Program Director on 709.33 Notification of termination regulation requirement, including that Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project, and that the notice shall include the reason for termination.
Training will be completed by 3/31/2024. A copy of the training completion and staff participating will be kept on file in the Program Director's Office.
The Clinical Director will review Discharge Documents after each client discharge upon completion to ensure that they include Notifications of termination completed according to the 709.33 Notification of termination regulation requirement. After each discharge review, the Clinical Director will follow-up with staff responsible for completing notification of terminations accordingly.
During regular (e.g. biannual) client file reviews, The PHMC Compliance Department will monitor that Notifications of termination are completed according to the 709.33 Notification of termination regulation requirement. The Compliance Department will report any findings to the Program Director for internal Plan of Correction. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake sand admission process, a psychosocial evaluation of the client in two of three applicable client records reviewed.
The facility policy and procedure manual states that the psychosocial evaluation is to be completed within 30 days of admission.
Client # 1 was admitted on December 19, 2023 and was still active at the time of the inspection. There was no psychosocial evaluation of the client documented in the record at the time of the inspection.
Client # 2 was admitted on December 6, 2023 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed by January 6, 2024, per the facility policy; however, the evaluation was completed on January 22, 2024.
This is a repeat citation from the August 3, 2023 annual licensing renewal 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 documenting the psychosocial evaluation will be trained by the Program Director on the § 709.51(b)(6) regulation requirement and the facility's relevant policy and procedures. The training will include the requirement to complete psychosocial evaluations within 30 days of admission. Training will be completed by 3/31/2024. A copy of the training completion and staff participating will be kept on file in the Program Director's Office.
The Clinical Director will review psychosocial evaluations to ensure that they are completed according to § 709.51(b)(6) regulation requirement and the facility's relevant policy and procedures, within 30 days of admission. The Clinical Director will assign the psychosocial evaluation to be completed by 3/31/2024 for client #1. The Clinical Director will track the completion of due and coming due psychosocial evaluations and will review the tracking at least weekly during Clinical Team meetings with all the clinicians, and during individual staff supervision meetings with each of the clinicians for their assigned caseloads. The Clinical Director will report at least monthly to the Program Director on psychosocial evaluation completions , that they are done according to the § 709.51(b)(6) regulation requirement and the facility's relevant policy and procedures.
During regular (e.g. biannual) client file reviews, The PHMC Compliance Department will monitor that psychosocial evaluations are documented within thirty days of admission in the client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
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709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in five of five applicable client records reviewed.
Client # 1 was admitted on December 19, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 23, 2024 and indicated the client was to receive weekly individual counseling sessions. There were no individual counseling sessions documented in the record during the week of January 28, 2024 through February 3, 2024.
Client # 2 was admitted on December 6, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 5, 2024 and indicated the client was to receive weekly individual counseling sessions. There were no individual counseling sessions documented in the record during the weeks of January 7, 2024 through January 13, 2024 and January 28, 2024 through February 3, 2024.
Client # 4 was admitted on June 9, 2023 and was still active at the time of the inspection. Treatment plan updates were completed on September 8, 2023, January 8, 2024, January 13, 2024, and January 23, 2024 and all indicated the client was to receive weekly individual counseling sessions. There was no individual counseling session documented from the start of the reviewed period on October 1, 2023 through January 2, 2024.
Client # 5 was admitted on July 13, 2023 and was discharged on October 20, 2023. A treatment plan update was completed on September 13, 2023 and indicated the client was to receive weekly individual counseling sessions. The only individual counseling session documented during the reviewed period of October 1, 2023 through the client's discharge was on October 12, 2023.
Client # 7 was admitted on November 15, 2022 and was discharged on December 6, 2023. A treatment plan update was completed on February 15, 2023 and indicated the client was to receive weekly individual counseling sessions. The only individual counseling session documented during the reviewed period of October 1, 2023 through the client's discharge was on November 16, 2023.
This is a repeat citation from the August 3, 2023 annual licensing renewal 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 counseling services will be trained by the Program Director on the 709.52(c) Provision of Counseling Services regulation requirement, and the project's relevant policies and procedures. The training will include the requirement that the project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan. The training will include the requirement that staff follow the plans of correction as approved by The Department. Training will be completed by 3/31/2024. A copy of the training completion and staff participating will be kept on file in the Program Director's Office.
The Clinical Director will review the clinicians' weekly schedules and counseling service documentation to ensure that they are completed according to individual treatment and rehabilitation plans. The Clinical Director will track the completion of due and coming-due counseling service documentation and will review the tracking at least weekly during Clinical Team meetings with all the clinicians, and during individual staff supervision meetings with each of the clinicians for their assigned caseloads. The Clinical Director will report at least monthly to the Program Director on counseling service documentation completions , that they are done according to the individual treatment and rehabilitation plans.
During regular (e.g. biannual) client file reviews, The PHMC Compliance Department will monitor that documentation of counseling services are completed according to individual treatment and rehabilitation plans. The Compliance Department will report any findings to the Program Director for internal Plan of Correction. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include case consultation notes, in four of four applicable client records reviewed.
Client # 4 was admitted on June 9, 2023 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 5 was admitted on July 13, 2023 and was discharged on October 20, 2023. There were no case consultation notes documented in the record at the time of the inspection.
Client # 6 was admitted on September 8, 2022 and was discharged on December 14, 2023. There were no case consultation notes documented in the record at the time of the inspection.
Client # 7 was admitted on November 15, 2022 and was discharged on December 6, 2023. There were no case consultation notes documented in the client at the time of the inspection.
This is a repeat citation from the August 3, 2023 annual licensing renewal 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 case consultation will be trained by the Program Director on the 709.53(a)(8) Case Consultation Notes regulation requirement, and the project's relevant policies and procedures. The training will include the requirement 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, Case consultation notes. The training will also include the requirement that staff follow the plans of correction as approved by The Department. Training will be completed by 3/31/2024. A copy of the training completion and staff participating will be kept on file in the Program Director's Office.
The Clinical Director will review the Case consultation documentation to ensure that they are completed according 709.53(a)(8) Case Consultation Notes regulation requirement. The Clinical Director will assign case consultation notes to be completed by 3/31/2024 for client #4. The The Clinical Director will track the completion of due and coming-due Case consultation documentation and will review the tracking at least weekly during Clinical Team meetings with all the clinicians, and during individual staff supervision meetings with each of the clinicians for their assigned caseloads. The Clinical Director will report at least monthly to the Program Director on Case consultation documentation completions , that they are done according to 709.53(a)(8) Case Consultation Notes regulation requirement.
During regular (e.g. biannual) client file reviews, The PHMC Compliance Department will monitor that documentation of case consultation are completed according to 709.53(a)(8) Case Consultation Notes regulation requirement. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
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