D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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INTERIM HOUSE WEST
4108 PARKSIDE AVENUE
PHILADELPHIA, PA 19104

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Survey conducted on 07/18/2025

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on July 17, 2025 through July 18, 2025 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
704.6(e) LICENSURE Supervisory Meetings 704.6. Qualifications for the position of clinical supervisor. (e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
Observations Based on a review of personnel records, the facility failed to ensure clinical supervisors participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in that position in one of one applicable personnel record reviewed. Employee #2 was hired as a clinical supervisor on January 2, 2025. There was no documentation indicating monthly clinical supervision meetings were held during the months of March 2025 and May 2025. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The Program Director, Director of Compliance, and Clinical Supervisor will review 704.6(e) LICENSURE Supervisory Meetings regulations by 9/30/2025. All newly hired clinical supervisors at IHW will participate in documented monthly meetings with the Program Director to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level. A copy of the documentation of the clinical supervisor's monthly meetings with the Program Director will be kept on file in the staff members HR file. During staff orientation, within 15 days of hire, the Program Director will inform all newly hired clinical supervisors of the 704.6(e) Supervisory Meetings requirement, and the Program Director will schedule at least 6 months of monthly supervisory meetings with the clinical supervisor. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level. During regular (e.g. monthly ) supervision meetings with the PHMC Managing Director of Mental Health Services, the Program Director will report on the progress of ensuring scheduling, completion, and required documentation of the Clinical Supervisor's Supervisory meetings with the Program Director. Documentation of the Clinical Supervisor's Supervisory meetings will be sent to the Clinical Supervisor's HR file. Results of the compliance documentation reviews will be forwarded to the Director of Compliance, and PHMC Managing Director of Mental Health Services for follow-up. The Program Director, Clinical Supervisor, and Director of Compliance will be trained by the Program Director on the requirements of 704.6(e) LICENSURE Supervisory Meetings regulations and on this plan of correction by 9/30/25, and the plan will be fully implemented by 9/30/2025. A copy of staff training participation documentation will be kept on file in the staff members' training files.
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.
Observations Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed the mandatory 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory time frame in one of one applicable personnel record reviewed. Employee #3 was hired as a counselor on February 12, 2024. The HIV/AIDS and TB/STD and other health topics trainings were due to be completed no later than February 12, 2025. There was documentation showing the HIV/AIDS training was completed; however, there was no documentation indicating the TB/STD and other health topics training was completed as of the date of the inspection. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The Program Director will review existing documentation of Mandatory Communicable Disease Training by 9/30/2025. Supervisors will instruct staff members on how to sign up and complete the training courses, including 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics, and will develop a plan to complete those DDAP training courses by 9/30/2025. All active staff at IHW without completed Mandatory Communicable Disease Trainings on file at IHW within required timeframes as described by 704.11(c)(1) will complete those training courses by 9/30/2025. 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. Supervisors will review the PA Code 704.11 DDAP Training requirements and timeframes with the staff members during their Training Plan development meeting. Supervisors will instruct staff members on how to sign up and complete the training courses, including 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics, and will develop a plan to complete those DDAP training courses. During regular supervision/staff meetings (e.g. monthly), supervisors will review staff compliance with meeting the DDAP training course completion requirements. Supervisors will review their assigned staff member's course completions with the program director during their regular supervisor staff meetings (e.g. monthly). Compliance with staff training course completion requirements will be documented on staff supervision notes. All staff and supervisors at IHW will be trained on 704.11(c)(1) Mandatory Communicable Disease Training regulation and this plan of correction by the Program Director by 9/30/2025 and the plan will be fully implemented by 9/30/2025. A copy of staff training participation documentation will be kept on file in the staff members' training files.
704.11(c)(2) LICENSURE CPR CERTIFICATION 704.11. Staff development program. (c) General training requirements. (2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
Observations Based on a review of personnel records and the project's June 15, 2025 through July 12, 2025 employee work schedule, the facility failed to ensure a sufficient number of staff persons were trained in CPR and first aid during the project's hours of operation. The project's hours of operation are 24/7 as they are a residential program. There was no documentation of employee CPR certification during the following days and times, due to many staff having expired CPR certification: 3, 2025 from 5:00PM - 12:00AM 4, 2025 from 12:00AM - 8:30AM and 5:00PM - 12:00AM 5, 2025 from 12:00AM - 9:00AM and 5:00PM - 12:00AM 6, 2025 from 12:00AM - 1:00AM and 5:00PM - 12:00AM 7, 2025 from 12:00AM - 1:00AM 10, 2025 from 5:00PM - 12:00AM 11, 2025 from 12:00AM to 8:30AM and 5:00PM - 12:00AM 12, 2025 from 12:00AM - 9:00AM and 5:00PM - 12:00AM These findings were reviewed with facility staff during the licensing process.	Plan of Correction The Program Director will review existing documentation of staff CPR and first aid training documentation by 9/30/2025. Supervisors will instruct staff members on how to sign up and complete the CPR certification and first aid training courses, and will develop a plan for all staff at IHW to have documentation of completed CPR certification and first aid training courses by 9/30/2025. All active staff at IHW without completed CPR certification and first aid training courses on file at IHW within required timeframes as described by 704.11(c)(2) will complete those training courses by 9/30/2025. 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. Supervisors will review the PA Code 704.11 DDAP Training requirements and timeframes with the staff members during their Training Plan development meeting. Supervisors will instruct staff members on how to sign up and complete the training courses, including CPR certification and first aid training, and will develop a plan to complete those DDAP training courses. During regular supervision/staff meetings (e.g. monthly), supervisors will review staff compliance with meeting the DDAP training course completion requirements. Supervisors will review their assigned staff member's course completions with the program director during their regular supervisor staff meetings (e.g. monthly). Compliance with staff training course completion requirements will be documented on staff supervision notes. All staff and supervisors at IHW will be trained on 704.11(c)(2) CPR Certification regulation and this plan of correction by the Program Director by 9/30/2025 and the plan will be fully implemented by 9/30/2025. A copy of staff training participation documentation will be kept on file in the staff members' training files.
704.11(d)(2) LICENSURE Annual Training Requirements 704.11. Staff development program. (d) Training requirements for project directors and facility directors. (2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as: (i) Fiscal policy. (ii) Administration. (iii) Program planning. (iv) Quality assurance. (v) Grantsmanship. (vi) Program licensure. (vii) Personnel management. (viii) Confidentiality. (ix) Ethics. (x) Substance abuse trends. (xi) Developmental psychology. (xii) Interaction of addiction and mental illness. (xiii) Cultural awareness. (xiv) Sexual harassment. (xv) Relapse prevention. (xvi) Disease of addiction. (xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
Observations Based on a review of personnel records, the facility failed to ensure the project director and the facility director completed at least 12 clock hours of annual training, during the facility's January 2024 through December 2024 training year, in one of one applicable personnel record reviewed. Employee #1 was hired as the project director on June 28, 2017. There was documentation indicating only 10.5 hours of annual training were completed during the training year reviewed. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The Program Director, Director of Compliance, and PHMC Managing Director of Mental Health Services will review existing documentation of staff training hour documentation by 9/30/2025. The Supervisors will instruct staff members on how to sign up and complete training hours, and will develop a plan for all staff, including the program (project/facility) director, at IHW to have documentation of completed training hours by 9/30/2025. All active staff at IHW without completed training hour courses on file at IHW within required timeframes as described by 704.11(d)(2) will complete those training courses during the training year (calendar year) as required, by 12/31/2025. During staff orientation, within 30 days of hire, all new staff, including the program (project/facility) director, will complete the initial IHW Individual Staff Training Plan with their assigned supervisor. Every year, during the month of January, all existing staff, including the program (project/facility) director, will complete the IHW Individual Staff Training Plan annual update Plan with their assigned supervisor. Supervisors will review the PA Code 704.11 DDAP Training hour requirements and timeframes with the staff members during their Training Plan development meeting. Supervisors will instruct staff members on how to sign up and complete the training hours, and will develop a plan to complete those DDAP training courses. During regular supervision/staff meetings (e.g. monthly), supervisors will review staff compliance with meeting the DDAP training course completion requirements. Supervisors will review their assigned staff member's course completions with the program director during their regular supervisor staff meetings (e.g. monthly). The Managing Director of Mental Health Services will review the training hour completions with the program (project/facility) director during their regular supervisor staff meetings (e.g. monthly). All staff, including the program (project/facility) director's Compliance with staff training course completion requirements will be documented on staff supervision notes. All staff and supervisors at IHW will be trained on 704.11(d)(2) LICENSURE Annual Training Requirements and on this plan of corrective by the Program Director by 9/30/2025 and the plan will be fully implemented by 9/30/2025. A copy of staff training participation documentation will be kept on file in the staff members' training files.
705.2 (1) LICENSURE Building exterior and grounds. 705.2. Building exterior and grounds. The residential facility shall: (1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
Observations Based on a physical plant inspection, conducted on July 17, 2025, the facility failed maintain all structures, fences, and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety. At the time of the inspection , the metal steps and the landing platform of the children's playground equipment had holes, broken edges, peeling sheet metal, and rust. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Effective as of the notice of these findings on 7/18/2025, The Program Director closed the on-grounds playground equipment and the playground area. On 7/18/2025 The Program Director instructed all IHW staff and clients that the playground area is closed and no clients or staff are to make use of it until repairs and/or replacement of defective equipment are completed. All staff and supervisors responsible for Building exterior and grounds will be trained by the Program Director on the 705.2 (1) Building exterior and grounds regulation requirement and on this Plan of Correction by 9/30/2025. The training will include the requirement that the residential facility shall maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.. Training will be completed by 9/30/2025. A copy of the training completion and staff participating will be kept on file in the staff members training files. The Program Director will review options for repairing and/or replacing playground equipment with the Managing Director of Mental Health Services and the PHMC Facilities Director by 9/30/2025. A plan for repairing and/or replacing playground equipment will be developed by 10/30/2025. Repairs and/or replacements of playground equipment will be completed by 12/31/2025. The playground area will be closed until repairs and/or replacement of defective equipment are completed. During regular (e.g. daily) building exterior and grounds checks, The Facility Manager or Program Director's designee for Facilities Management will review that building exterior and grounds are according to 705.2 (1) 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.
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, conducted on July 17, 2025, the facility failed to ensure the grounds of the facility were clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors and that the exterior of the building and the building grounds or yard are free of hazards. At the time of the inspection, the children's playground is surrounded by many apple trees and the playground yard had apples lying on the ground throughout. Many of the apples were rotting and decaying, had bugs on them, and caused apple stains on the playground floor. Also, in the basement laundry room, there was a shelf holding three dryers and the front panel of the shelf was bowing inward and did not appear safe. Also, in the swing room of bedroom 303A, there was a hole in the wall. Additionally, in the preschool room, there was peeling paint on the back wall and there was a trash can overflowing with trash in and around the can. Throughout the preschool room, the carpet and floor had what appeared to be dirt, grime, and/or food. This is a repeat citation from the July 24, 2024 annual licensing renewal inspection and the February 6, 2024 provisional license follow-up inspection. These findings were reviewed with facility staff during the licensing process.	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 9/30/2025. 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. The exterior of the building and the building grounds or yard shall be free of hazards. Training will be completed by 9/30/2025. A copy of the training completion and staff participating will be kept on file in the staff members training files. Issues identified by the DDAP inspection were addressed as follows: the playground area is closed as of 7/18/25. The playground area and grounds were cleared of apples and pests as of 7/31/25 by PHMC groundskeepers. Facilities tickets were sent to the PHMC Facilities department on 7/19/2025 for the hole in the wall in paint in the back wall of the preschool room. Completion of these repairs are expected by 9/30/2025. The basement laundry room shelf area was placed off-limits from use effective 7/18/2025 due to safety concerns. Facilities tickets were sent to the PHMC Facilities department on 7/19/2025 for assessment and repairs as needed. Safety concerns identified by facilities department will be replaced or repaired by 9/30/2025. The overflowing trash in the preschool room was emptied on 7/18/2025. The preschool room carpet and floor was vacuumed and swept and cleared of dirt, grim, and/or food on 7/18/2025. During regular (e.g. daily) building exterior and grounds checks, The Facility Manager or Program Director's designee for Facilities Management will review that building exterior and grounds are according to 705.2 (2) Building exterior and grounds regulatory requirements and that staff are appropriately completing daily building exterior and groundskeeping tasks using the IHW RA daily facility and grounds checklist. 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. Copies of daily IHW facility and grounds checklists will be kept on file in the Facility Manager's Program Director's designee's office. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database. The Program Director will report completion of issues identified by the DDAP Inspector to The PHMC Managing Director of Mental Health Services during regular (e.g. monthly ) Supervision Meetings. Documentation of these Supervision meetings will be kept in the Program Director's employee file.
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, conducted on July 17, 2025, the facility failed to ensure each residential bedroom had a bed with a solid foundation and fire-retardant mattress in good repair. At the time of the inspection, the mattresses in client bedrooms 301A and 302B were ripped and not in good repair. These findings were reviewed with facility staff during the licensing process.	Plan of Correction All staff and supervisors responsible for ensuring Sleeping accommodations quality will be trained by the Program Director on the 705.5 (a) (1) LICENSURE Sleeping accommodations requirement and on this Plan of Correction by 9/30/2025. The training will include the requirement that in each residential facility bedroom, each resident shall have the following: A bed with solid foundation and fire retardant mattress in good repair. Training will be completed by 9/30/2025. A copy of the training completion and staff participating will be kept on file in the staff members training files. Issues identified by the DDAP inspection were addressed as follows: replacement mattresses for client bedrooms 301A and 302B were ordered 7/19/2025 with expected replacement on or before 9/30/25. During regular (e.g. daily) room checks, The Facility Manager or Program Director's designee for Facilities Management will review that sleeping accommodations are kept according to 705.5 (a)(1) Speeping accommodation regulatory requirements and that staff are appropriately completing daily tasks using the IHW RA daily facility and grounds checklist. 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. Copies of daily IHW facility and grounds checklists will be kept on file in the Facility Manager's or the Program Director's designee's office. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database. The Program Director will report completion of issues identified by the DDAP Inspector to The PHMC Managing Director of Mental Health Services during regular (e.g. monthly ) Supervision Meetings. Documentation of these Supervision meetings will be kept in the Program Director's employee file.
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.
Observations Based on a physical plant inspection, conducted on July 17, 2025, the facility failed to ensure each bathroom was provided with paper towels or a mechanical dryer. At the time of the inspection, there was no evidence hand towels were being provided to clients and there were no paper towels or functional mechanical dryers in the bathrooms of client bedrooms 201A/B, 202A/B, 203A/B, 205A/B, 304A/B, and 305A/B. These findings were reviewed with facility staff during the licensing process.	Plan of Correction All staff and supervisors responsible for ensuring facility upkeep will be trained by the Program Director on the 705.6 (2) LICENSURE Bathrooms requirement and on this Plan of Correction by 9/30/2025. The training will include that the residential facility shall Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom. Training will be completed by 9/30/2025. A copy of the training completion and staff participating will be kept on file in the staff members training files. Issues identified by the DDAP inspection were addressed as follows: each bathroom was provided with paper towels as of 7/18/25 , including in the bathrooms of client bedrooms 201A/B, 202A/B, 203A/B, 205A/B, 304A/B, and 305A/B. During regular (e.g. daily) facility checks, The Facility Manager or Program Director's designee for Facilities Management will review that bathrooms are kept according to 705.6 (2) bathroom regulatory requirements and that staff are appropriately completing daily facility and grounds tasks using the IHW RA daily facility and grounds checklist. 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. Copies of daily IHW facility and grounds checklists will be kept on file in the Facility Manager's Program Director's designee's office. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database. The Program Director will report completion of issues identified by the DDAP Inspector to The PHMC Managing Director of Mental Health Services during regular (e.g. monthly ) Supervision Meetings. Documentation of these Supervision meetings will be kept in the Program Director's employee file.
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, conducted on July 17, 2025, 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, located in the nursing station, had a toilet lid broken in half and tried to be repaired with what appeared to be caulking. Also, in the bathroom located in the preschool room, there was a loose and missing tile on the floor. Additionally, there were various issues noted in client bathrooms: client bathroom 301A/B, there was a broken vanity door client bathroom 304A/B, there was repair tape above the bathtub and broken drywall and missing tiles at the bottom of the bathtub client bathroom 202A/B, there was a rusted metal drywall corner sticking out from the wall, broken drywall, and missing tile client bathroom 203A/B, the toilet was continuously running and unable to be stopped and fixed client bathroom 205A/B, there appeared to be dirt, mold, mildew, or grime located on the shower wall and along the bathtub This is a repeat citation from the July 24, 2024 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.	Plan of Correction All staff and supervisors responsible for ensuring facility upkeep will be trained by the Program Director on the 705.6 (7) LICENSURE Bathrooms requirement and on this Plan of Correction by 9/30/2025. The training will include that the residential facility shall Maintain each bathroom in a functional, clean and sanitary manner at all times. Training will be completed by 9/30/2025. A copy of the training completion and staff participating will be kept on file in the staff members training files. Issues identified by the DDAP inspection were addressed as follows: a facility ticket was placed by the Program Director on 7/19/25 for the following: a toilet lid replacement in the nursing station, loose and missing tile in the preschool bathroom, client bathroom 301A/B broken vanity door, client bathroom 304A/B, repair above the bathtub and broken drywall and missing tiles at the bottom of the bathtub; client bathroom 202A/B, rusted metal drywall corner replacement/repair and broken drywall repair, and missing tile replacement; client bathroom 203A/B toilet repair for continuously running and unable to be stopped and fixed; client bathroom 205A/B, dirt, mold, mildew, or grime removal from the shower wall and along the bathtub. Expected completion of ticket items is 10/30/2025. During regular (e.g. daily) facility checks, The Facility Manager or Program Director's designee for Facilities Management will review that bathrooms are kept according to 705.6 (7) bathrooms regulatory requirements and that staff are appropriately completing daily facility and grounds tasks using the IHW RA daily facility and grounds checklist. 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. Copies of daily IHW facility and grounds checklists will be kept on file in the Facility Manager's Program Director's designee's office. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database. The Program Director will report completion of issues identified by the DDAP Inspector to The PHMC Managing Director of Mental Health Services during regular (e.g. monthly ) Supervision Meetings. Documentation of these Supervision meetings will be kept in the Program Director's employee file.
705.11 (2) (iv) LICENSURE Child care. 705.11. Child care. (2) Interior space. The residential facility shall: (iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
Observations Based on a physical plant inspection, conducted on July 17, 2025, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks. The facility provides custodial care for children, and at the time of the inspection, there were various cleaning agents and bleach unsecured in the bathroom vanities located in bedrooms 201A/B, 202A/B, 203A/B, and 205A/B. None of the vanities had safety latches and were not able to be locked. These findings were reviewed with facility staff during the licensing process.	Plan of Correction All staff and supervisors responsible for ensuring facility upkeep will be trained by the Program Director on the 705.11 (2) LICENSURE Child care requirement and on this Plan of Correction by 9/30/2025. The training will include that the residential facility shall Secure all hazardous and poisonous substances and materials with safety latches or locks. Training will be completed by 9/30/2025. A copy of the training completion and staff participating will be kept on file in the staff members training files. Issues identified by the DDAP inspection were addressed as follows: hazardous and poisonous substances and materials were removed from unlocked areas in bedrooms 201A/B, 202A/B, 203A/B, and 205A/B, and placed in locked storage closets where they could be retrieved and returned by adult clients as needed. A facility ticket was placed by the Program Director on 7/19/25 for the following: installation of safety latched on unsecured bathroom vanities, including those in located in bedrooms 201A/B, 202A/B, 203A/B, and 205A/B. Expected completion of ticket items is 10/30/2025. During regular (e.g. daily) facility checks, The Facility Manager or Program Director's designee for Facilities Management will review that physical plant childcare areas are kept according to 705.11 (2) child care regulatory requirements and that staff are appropriately completing daily tasks using the IHW RA daily facility and grounds checklist. 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. Copies of IHW RA daily facility and grounds checklists will be kept on file in the Facility Manager's Program Director's designee's office. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database. The Program Director will report completion of issues identified by the DDAP Inspector to The PHMC Managing Director of Mental Health Services during regular (e.g. monthly ) Supervision Meetings. Documentation of these Supervision meetings will be kept in the Program Director's employee file.
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.
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 three of three applicable client records reviewed. The facility policy and procedure manual stated the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice. Client #4 was admitted on December 20, 2024 and was discharged against medical advice on January 8, 2025. There was no documentation in the record indicating the emergency contact was notified of the client's discharge against medical advice. Client #5 was admitted on December 12, 2024 and was discharged against medical advice on February 14, 2025. There was no documentation in the record indicating the emergency contact was notified of the client's discharge against medical advice. Client #6 was admitted on November 6, 2024 and was discharged against medical advice on April 11, 2025. There was no documentation in the record indicating the emergency contact was notified of the client's discharge against medical advice. This is a repeat citation from the July 24, 2024 annual licensing renewal inspection, 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.	Plan of Correction By 9/30/2025, all staff and supervisors responsible for discharge notifications will be trained by the Program Director on this Plan of Correction and on 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. The Clinical Director will report completion of notifications to emergency contacts to The Program Director during regular (e.g. monthly ) Supervision Meetings. Documentation of these Supervision meetings will be kept in the Clinical Director's employee file. All staff and supervisors will be trained on this plan of corrective by the Program Director and the plan fully implemented by 9/30/2025.
709.28 (a) (1) LICENSURE Confidentiality � 709.28. Confidentiality. (a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code � 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to: (1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
Observations Based on a review of client records, the facility failed to maintain the confidentiality of client identity and records by having facility procedures which include a description of how the project plans to address the security and release of electronic and paper records. At the time of the review of client records, there was documentation of a discharge summary for client #7 located in the paper chart of client #6. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The Project Director will conduct an internal review of all active client file documentation by 9/30/2025, with the purpose of ensuring that client-oriented information in electronic and paper records is limited to the client in whose record the information is contained. Errors and misplaced documentation discovered during the internal review will be amended or removed from the client record in accordance with 709.28 (a) (1) Confidentiality regulatory requirements. 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 Confidentiality of client information. Within 7 days of hire, During staff orientation and prior to entering client information into client records, all staff who are responsible for entering information into the client record will be instructed by the Clinical Director on � 709.28.(a)(1) Confidentiality regulatory requirements. During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that information is limited to the client of record 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 entering client record information will be trained on the requirements of 709.28 (c) (1) Confidentiality and on this plan of corrective by the Program Director by 9/30/2025 and the plan will be fully implemented by 9/30/2025. A record of staff participation in the training course will be kept in the staff training records.
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. At the time of the inspection, which was conducted on July 17, 2025, there were two filing cabinets where the active records are stored, and both cabinets were not locked during the physical plant inspection. Additionally, there were four closed records sitting on the center shelf in the administration room and there was no staff actively working on the records when observed. Per further discussions with facility staff, the Licensing Representative was informed the administration room, where the two client record filing cabinets are stored, can be locked; however, throughout the inspection, as well as after the exit interview conducted on July 18, 2025, the administration room was not locked. These findings were reviewed with facility staff during the licensing process.	Plan of Correction Client records were locked in the record filing cabinets by the Program Director by E.O.B. on 7/18/2025. The Clinical Director and Program Director will be responsible for ensuring that hard copy client records are secured within the locked storage cabinets. Client records are to be stored locked within the cabinets at all times except when in use in the immediate presence of staff actively working on those client records. As part of staff orientation, within the first 7 days of hire, prior to working with client records, the Clinical Supervisor will instruct any new staff member who has responsibility to enter or retrieve or review information contained in client records, to comply with 709.28 (b) Confidentiality regulations, including that Client records are to be stored locked within the records cabinets at all times except when in use in the immediate presence of staff actively working on those client records. During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that client records comply with 709.28 (b) Confidentiality regulations, and that Client records are stored locked within the records cabinets at all times except when in use in the immediate presence of staff actively working on those client records. The Compliance Department will report any findings to the Program Director for internal Plan of Correction. All staff and supervisors responsible for securing and retrieving client record information will be trained on the requirements of 709.28 (b) Confidentiality and on this plan of corrective by the Program Director by 9/30/2025 and the plan will be fully implemented by 9/30/2025. A record of staff participation in the training course will be kept in the staff training records.
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.
Observations Based on a review of client records, the facility failed to document the specific information to be released on a consent form in one of seven client records reviewed. Client #6 was admitted on November 16, 2024 and was discharged on April 11, 2025. A release of information form to another treatment provider was signed by the client; however, there was no specific information to be disclosed documented on the release form. This finding was reviewed with facility staff during the licensing process.	Plan of Correction By 9/30/2025, The Program Director will conduct an internal review of all active client file documentation of Consent for the Release of Information (ROI), including that documentation complies with � 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. Any ROI documentation on file in the client record which does not include details about the "specific information" disclosed will be revised or recompleted by the client and their assigned therapist. 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) (2) Confidentiality requirements. During the intake admission process, and at any time before release of information occurs, Consent for Release of Information will be discussed with the client 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. Documentation of the consent and the disclosure will include the "specific information" disclosed. 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, and that the ROIs include specific information to be disclosed. The Compliance Department will report any findings to the Program Director for internal Plan of Correction. All staff and supervisors will be trained by the Program Director on the requirements of 709.28 (c) (2) Licensure Confidentiality and on this plan of corrective by the Program Director by 9/30/2025 and the plan will be fully implemented by 9/30/2025.
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 release of information form in one of seven client records reviewed. Client #6 was admitted on November 16, 2024 and was discharged on April 11, 2025. A release of information form to another treatment provider was signed by the client; however, there was no purpose of the disclosure documented on the release form. This finding was reviewed with facility staff during the licensing process.	Plan of Correction By 9/30/2025, The Program Director will conduct an internal review of all active client file documentation of Consent for the Release of Information (ROI), including that documentation complies with � 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. Any ROI documentation on file in the client record which does not include details about the "Purpose of disclosure" disclosed will be revised or recompleted by the client and their assigned therapist. 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) (3) Confidentiality requirements. During the intake admission process, and at any time before release of information occurs, Consent for Release of Information will be discussed with the client 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. Documentation of the consent and the disclosure will include the "Purpose of disclosure". 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, and that the ROIs include the Purpose of disclosure. The Compliance Department will report any findings to the Program Director for internal Plan of Correction. All staff and supervisors will be trained by the Program Director on the requirements of 709.28 (c) (3) Licensure Confidentiality and on this plan of corrective by the Program Director by 9/30/2025 and the plan will be fully implemented by 9/30/2025.
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.
Observations Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in one of seven client records reviewed. Client #6 was admitted on November 16, 2024 and was discharged on April 11, 2025. A release of information form to another treatment provider was signed by the client; however, there was no documentation in the record indicating a copy of the consent form was offered to the client. This finding was reviewed with facility staff during the licensing process.	Plan of Correction By 9/30/2025, the Project Director will conduct an internal review of all active client file documentation of Consent for the Release of Information (ROI), including that A copy of a client consent shall be offered to the client and a copy maintained in the client record. The Program Director will instruct therapists to correct Errors and incomplete documentation of Consent for ROI discovered during the internal review to be amended, signed, and dated, with consent from the client, by 9/30/2025. 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 (d) Licensure Confidentiality and on this plan of corrective by the Program Director and the plan will be fully implemented by 9/30/2025.
709.31 (a) LICENSURE Data collection system � 709.31. Data collection system. (a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
Observations Based on an administrative review, the project failed to maintain a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives. Per a discussion with facility staff, the facility currently uses an electronic medical record for progress notes and paper charts for all other documentation. All active paper charts are housed on the first-floor administration area and all closed paper charts are housed in the chart room in the basement. It took facility staff approximately 45 minutes to retrieve the only three active charts requested by the Licensing Representative. Also, it took facility staff approximately one hour to locate a closed chart. After a discussion with facility staff, there was difficulty locating the chart due to the small size of it. Additionally, throughout the first day of the inspection, four different facility staff attempted to bring various documents for charts that were filed elsewhere and not maintained in either the paper charts or electronic record. Another staff member also attempted to show documents on their work computer. When the Licensing Representative requested to see documents that were missing from the reviewed records, the documents that were shown were ones that did not need to be reviewed. Finally, the facility was unable to identify, on the client list provided, the reasons for the discharge of the clients. These findings were reviewed with the facility staff during the licensing process.	Plan of Correction By 9/30/2025, the Project Director will conduct a thorough internal review of the data collection/filing system for all active client records, and discharged client records from FY 2024 to present. The review will include that client records are kept in the location and in the order as required by 709.31 (a) Data Collection system and IHW agency policy. Client Records and Materials not in compliance with the data collection/filing system policy and regulations will be reordered or returned to their orderly location by 9/30/2025. During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that the filing system is in compliance with 709.31 (a) Data Collection system and IHW agency policy, and that records and data are retrievable in an efficient and timely manner. The Compliance Department will report any findings to the Program Director for internal Plan of Correction. As part of staff orientation, within the first 7 days of hire, prior to working with client records, the Clinical Supervisor will instruct any new staff member who has responsibility to enter or retrieve information contained in client records, to comply with 709.31 (a) and IHW agency policy. The Clinical Director and Program Director, by 9/30/2025, will instruct all staff responsible for entering or reporting client discharge status that Client discharge information, including the reason for discharge, is kept in the client record under the "Discharge" section and can be retrieved from that section or from the electronic health record (aka "C.R.S.") using the "Client Discharge Report". All staff and supervisors will be trained on the requirements of 709.31 (a) Data Collection system and IHW agency policy, and on this plan of corrective by the Program Director and the plan will be fully implemented by 9/30/2025.
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.
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 record reviewed. Client #7 was admitted on October 31, 2024 and was administratively discharged on May 29, 2025. There was no documentation, in the record, indicating 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.	Plan of Correction As part of staff orientation, within the first 7 days of hire, prior to conducting a client discharge, the Clinical Supervisor will instruct any new staff member who has responsibility to conduct client discharges, to comply with 709.33 (a) Notification of Termination, including that 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. At the time of a client Discharge when they are involuntarily discharged, on the day of their discharge, the Clinical Director will ensure that the program is in compliance with 709.33 (a) LICENSURE Notification of termination, by ensuring that the client was notified in writing of a decision to involuntarily terminate the client' s treatment at the project. The notice shall include the reason for termination. The Clinical Director will review discharge completion and due-date status at every (e.g. weekly) Clinical Team Meeting, and will consult staff about discharge completions during that meeting, including that clients were notified of decisions to involuntarily terminate the client's treatment at the project, and that the notice included the reason for termination. The Clinical Director will review discharge completion at every (e.g. monthly) Counselor Individual staff meeting, and will consult staff about their discharge completions during that meeting. Compliance with meeting notification requirements for decisions to involuntarily terminate the client's treatment at the project, and that the notice included the reason for termination, for clients on Counselor's caseload will be documented on the Counselor's Individual Staff Supervision Notes. The Clinical Director will report Discharge Completions to the Program Director during regular (e.g. monthly) Supervision meetings. Compliance with notification requirements for discharged clients will be documented on The Clinical Director's Individual Staff Supervision Notes. During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that client discharge information includes notice of termination in writing, according to 709.33 (a), including that Project staff notified 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. 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 709.33 (a) Notification of termination, and on this plan of correction, by the Program Director, by 9/30/2025, and the plan will be fully implemented by 9/30/2025.
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 an administrative review, the facility failed to notify the Department within 3 business days following an event at the facility requiring the presence of police, fire, or ambulance personnel. There was documentation indicating police, fire, or ambulance personnel were onsite at the facility on May 29, 2025; however, there was no documentation showing the incident was reported to the Department at the time of the inspection. This finding was reviewed with facility staff during the licensing process.	Plan of Correction All staff and supervisors will be trained on the requirements of 709.34 (c)(4) Reporting of unusual incidents, and on this plan of correction, by the Program Director, by 9/30/2025. A copy of staff training participation documentation will be kept on file in the staff members' training files. The training will include that 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: Event at the facility requiring the presence of police, fire or ambulance personnel. 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. Supervisors will review Incident Reporting Training requirements and timeframes with the staff members during their Training Plan development meeting. Formal Incident Report Training Course Completion will be completed Once within 90 days of hire and every year thereafter. Supervisors will instruct staff members on how to sign up and complete the training courses, including PHMC's Incident Reporting training. During regular supervision/staff meetings (e.g. monthly), supervisors will review staff compliance with meeting training course completion requirements. Supervisors will review their assigned staff member's course completions with the program director during their regular supervisor staff meetings (e.g. monthly). Compliance with staff training course completion requirements will be documented on staff supervision notes. The training details PHMC Incident Reporting Policy and Procedures, which provides details of sending unusual incident reports to the Department of Drug and Alcohol Programs (DDAP) using the Electronic Reporting System (ERS) for review and action. Following an unusual incident, the Program Director will be responsible for ensuring regulatory compliance with 709.34 (c) (4) Reporting of unusual incidents, 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: Event at the facility requiring the presence of police, fire or ambulance personnel. During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that incident report information is reported according to 709.34 (c) (4) Reporting of unusual incidents. The Compliance Department will report any findings to the Program Director for internal Plan of Correction. By 9/30/2025, All staff and supervisors will be trained on the requirements of 709.34 (c)(4) Reporting of unusual incidents, and on this plan of correction, by the Program Director, by 9/30/2025, and the plan will be fully implemented by 9/30/2025.
709.52(a) LICENSURE Individual TX and REHAB Plan 709.52. Treatment and rehabilitation services. (a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
Observations Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client in two of five applicable client records reviewed. Client #5 was admitted on December 12, 2024 and was discharged on February 14, 2025. There was no documentation, in the record, of an individual treatment and rehabilitation plan as of the date of the inspection. Client #6 was admitted on November 6, 2024 and was discharged on April 11, 2025. There was no documentation, in the record, of an individual treatment and rehabilitation plan as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.	Plan of Correction All staff and supervisors will be trained on the requirements of 709.52(a) Individual TX and REHAB Plan, and on this plan of correction, by the Program Director, by 9/30/2025. A copy of staff training participation documentation will be kept on file in the staff members' training files. The training will include that an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation. The Clinical Director will review treatment plan completion and due-date status on a regular (e.g. daily) basis on IHW's Treatment Plan tracker, which is kept in the Clinical Director's office, and will consult staff on a regular (e.g. daily) daily basis about treatment plan completions. The Clinical Director will review treatment plan completion and due-date status at every (e.g. weekly) Clinical Team Meeting using IHW's Treatment Plan tracker, and will consult staff about treatment plan completions during that meeting. The Clinical Director will review treatment plan completion and due-date status at every (e.g. monthly) Counselor and Intake Coordinator Individual staff meeting, using IHW's Treatment Plan tracker, and will consult staff about their treatment plan completions with clients during that meeting. Compliance with meeting due dates for Treatment Plans with clients on their caseload will be documented on the Counselor's Individual Staff Supervision Notes. The Clinical Director will report Treatment Plan Completions to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting due dates for Treatment Plans will be documented on The Clinical Director's Individual Staff Supervision Notes. During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that treatment plans are completed in a timely manner and are present in the official client record. 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 this plan of corrective by the Program Director, by 9/30/2025, and the plan will be fully implemented by 9/30/2025.
709.52(b) LICENSURE TX Plan update 709.52. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
Observations Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in two of five applicable client records reviewed. Client #3 was admitted on November 14, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 13, 2024 and the first treatment plan update was due to be completed no later than January 13, 2025; however, the update was completed on May 13, 2025. Client #7 was admitted on October 13, 2024 and was discharged on May 29, 2025. A treatment plan update was completed on December 27, 2024 and the next update was due to be completed on January 27, 2025; however, the update was completed on February 27, 2025. These findings were reviewed with facility staff during the licensing process.	Plan of Correction All staff and supervisors will be trained on the requirements of 709.52(b) TX Plan update, and on this plan of correction, by the Program Director, by 9/30/2025. A copy of staff training participation documentation will be kept on file in the staff members' training files. The training will include that Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days. The Clinical Director will review update treatment plan completion and due-date status on a regular (e.g. daily) basis on IHW's Treatment Plan tracker, which is kept in the Clinical Director's office, and will consult staff on a regular (e.g. daily) daily basis about treatment plan update completions. The Clinical Director will review treatment plan completion and due-date status at every (e.g. weekly) Clinical Team Meeting using IHW's Treatment Plan tracker, and will consult staff about treatment plan update completions during that meeting. The Clinical Director will review treatment plan update completion and due-date status at every (e.g. monthly) Counselor and Intake Coordinator Individual staff meeting, using IHW's Treatment Plan tracker, and will consult staff about their treatment plan update completions with clients during that meeting. Compliance with meeting due dates for update Treatment Plans with clients on their caseload will be documented on the Counselor's Individual Staff Supervision Notes. The Clinical Director will report Treatment Plan update Completions to the Project Director during regular (e.g. monthly) Supervision meetings. Compliance with meeting due dates for Treatment Plans will be documented on The Clinical Director's Individual Staff Supervision Notes. During regular (e.g. bi-annual) client file reviews, The PHMC Compliance Department will monitor that update treatment plans are completed in a timely manner and are present in the official client record. 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 this plan of corrective by the Program Director, by 9/30/2025, and the plan will be fully implemented by 9/30/2025.
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.
Observations Based on a review of client records and the project 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, the February 6, 2024 provisional license follow-up inspection, and July 24, 2024 annual licensing 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 17, 2025 through July 18, 2025 licensing inspection. A plan of correction for failing to keep the facility in good repair at all times was submitted and approved by the Department for the February 6, 2024 provisional license follow-up inspection and July 24, 2024 annual licensing inspection. Failing to keep the facility in good repair at all times was again found to be a deficiency in the July 17, 2025 through July 18, 2025 licensing inspection. This is a repeat citation from the July 24, 2024 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.	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 9/30/2025. 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 Mental Health 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 Mental Health Services for internal Plan of Correction. During regular (e.g. quarterly) Board reporting, the Program Director , in cooperation with the Managing Director of Mental Health Services, will report to the Board on progress and completion of these Plans 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 9/30/2025, and the plan fully implemented by 9/30/2025.