INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on January 13, 2026 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, 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, there were holes in the wall and there was a broken door handle in room 301 A/B swing. Additionally, there was a broken dresser/wardrobe in room 301A, a cracked outlet plate in room 306B, broken floor tiles in room 202A, and a broken cabinet door in the basement.
This is a repeat citation from the February 6, 2024 provisional follow-up inspection, July 24, 2024, and July 18, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: The Program Director submitted a facilities ticket to the PHMC facilities department requesting repair of holes in the wall and the broken door handle in room 301 A/B swing, replacement of the broken dresser/wardrobe in room 301A, replacement of the cracked outlet plate in room 306B, replacement/ repair of broken floor tiles in room 202A, and replacement/ repair of the broken cabinet door in the basement. The Program Director received an update from the PHMC Facilities Department that replacement and repairs for these items will be completed by 3/5/2026. Copies of the ticket and ticket completion report will be kept on file in the facilities ticketing database.
All staff and supervisors responsible for Building exterior and grounds will be trained by the Program Director or the Program Director's Designee on the 705.2 (2) Building exterior and grounds regulation requirement and on this Plan of Correction by 2/27/2026. 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 2/27/2026. A copy of the training completion and staff participating will be kept on file in the staff members training files.
During regular (e.g. daily) building exterior and grounds checks, The 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 Program Director's designee 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 Program Director's designee's office. Copy of facilities ticket requests and completion reports will be kept on file in the PHMC facilities database.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
At the time of the inspection, the first-floor group room had a large glass window with broken blinds that allowed anyone, outside of the group room, an opportunity to view counseling sessions at any time.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: The Program Director submitted a facilities ticket to the PHMC facilities department requesting replacement of privacy screening in the first floor group room. The Program Director received an update from the PHMC Facilities Department that replacement and repairs for this item was completed on 2/5/2026. Broken blinds were removed and "frosting" was added to the windows so that the inside of the room is not visible through the window. Copies of the ticket and ticket completion report are on file in the facilities ticketing database.
All staff and supervisors responsible for Counseling areas will be trained by the Program Director or the Program Director's Designee on the 705.4 (3) Counseling areas requirement and on this Plan of Correction by 2/27/2026. The training will include the requirement the residential facility shall ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room; Counseling room walls shall extend from the floor to the ceiling. Training will be completed by 2/27/2026. A copy of the training completion and staff participating will be kept on file in the staff members training files.
During regular (e.g. daily) building exterior and grounds checks, The Program Director's designee will review that building counseling rooms and kept according to 705.4 (3) Counseling room requirements and that staff are appropriately completing daily counseling room internal inspection tasks using the IHW RA daily facility and grounds checklist. The Program Director's designee 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 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.
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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.
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Observations
Based on a physical plant inspection, 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, in room 302B, there was a mattress that was ripped. Additionally, in room 201A, there was a broken bed frame.
This is a repeat citation from the July 18, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: a replacement bed frame was ordered by the Program Director on 1/14/2026 for client bedrooms 201A and a replacement mattress was ordered for client bedroom 302B . Replacements are expected to occur by 2/13/2026.
All staff and supervisors responsible for ensuring Sleeping accommodations quality will be trained by the Program Director or the Program Director's Designee on the 705.5 (a) (1) LICENSURE Sleeping accommodations requirement and on this Plan of Correction by 2/27/2026. 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 2/27/2026. A copy of the training completion and staff participating will be kept on file in the staff members training files.
During regular (e.g. daily) room checks, The 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 Program Director's designee for Facilities Management 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 office of the Program Director's designee for Facility Management. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to ensure all bathtubs and showers had slip-resistant surfaces.
At the time of the inspection, there was no slip-resistant surface in the bathtub and shower located in the bathroom of room 301 A/B.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: a replacement slip-resistant mat was ordered by the Program Director for the client bathroom of room 301A/B. Replacements occurred on 1/22/2026.
All staff and supervisors responsible for ensuring bathrooms quality will be trained by the Program Director or the Program Director's Designee on the 705.6 (4) bathrooms requirement and on this Plan of Correction by 2/27/2026. The training will include the requirement that the residential facility shall Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains; There shall be slip-resistant surfaces in all bathtubs and showers. Training will be completed by 2/27/2026. A copy of the training completion and staff participating will be kept on file in the staff members training files.
During regular (e.g. daily) room checks, The Program Director's designee for Facilities Management will review that bathrooms are kept according to 705.6 (4) bathrooms regulatory requirements and that staff are appropriately completing daily tasks using the IHW RA daily facility and grounds checklist. The Program Director's designee for Facilities Management 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 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.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate each toilet and washroom by an exhaust fan or a window.
At the time of the inspection, the exhaust fans, located in the bathrooms of rooms 305 A/B, 203 A/B, and 201 A/B were not operable and there were no operable windows in the bathrooms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: The Program Director submitted a facilities ticket to the PHMC facilities department requesting repair of the exhaust fans, located in the bathrooms of rooms 305 A/B, 203 A/B, and 201 A/B. The Program Director received an update from the PHMC Facilities Department that replacement and repairs for these items will be completed by 2/13/2026. Copies of the ticket and ticket completion report will be kept on file in the facilities ticketing database.
All staff and supervisors responsible for ensuring bathrooms quality will be trained by the Program Director or the Program Director's Designee on the 705.6 (5) Bathrooms requirement and on this Plan of Correction by 2/27/2026. The training will include the requirement that the residential facility shall ventilate toilet and wash rooms by exhaust fan or window. Training will be completed by 2/27/2026. A copy of the training completion and staff participating will be kept on file in the staff members training files.
During regular (e.g. daily) room checks, The Program Director's designee for Facilities Management will review that bathrooms are kept according to 705.6 (5) bathrooms regulatory requirements and that staff are appropriately completing daily tasks using the IHW RA daily facility and grounds checklist. The Program Director's designee for Facilities Management 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 office of the Program Director's designee for Facility Management. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
At the time of the inspection, there were various issues noted in several client bathrooms:
client bathroom 301A/B, there was an active leak under the sink as there was a bucket placed under the leak to catch the water; however, there was water overflowing from the bucket onto the cabinet and floor.
client bathroom 301A/B, there was a broken bathroom cabinet.
client bathroom 306A/B, the overhead light was missing a cover.
client bathrooms 304A/B, 204A/B. and 201A/B, there were broken and/or missing tub tiles.
client bathroom 304A/B, there was a broken toilet paper holder.
client bathroom 204A/B, there were broken floor tiles and a weakened subfloor.
client bathrooms 301A/B and 204A/B, there was damaged drywall from an old, previous water leak.
client bathroom 203A/B, the toilet was constantly running and would not turn off.
the toddler daycare room, there was a missing sink stopper cover.
the infant daycare room, there was a missing toilet tank cover and there was a large piece of plastic covering the toilet tank in place of a properly fitted toilet tank cover.
the first-floor common bathroom, there were several holes in the walls.
This is a repeat citation from the July 24, 2024 and July 18, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: The Program Director submitted a facilities ticket to the PHMC facilities department requesting repairs in client bathroom 301A/B for an active leak under the sink ; repair/replacement in client bathroom 301A/B for a broken bathroom cabinet ; repair/replacement in client bathroom 306A/B for an overhead light missing a cover; repair/replacement in client bathrooms 304A/B, 204A/B. and 201A/B, for broken and/or missing tub tiles; repair/replacement in client bathroom 304A/B for a broken toilet paper holder; repair/replacement in client bathroom 204A/B for broken floor tiles and a weakened subfloor; repair/replacement in client bathrooms 301A/B and 204A/B for damaged drywall ; repair/replacement in client bathroom 203A/B for toilet constantly running/ not turning off; repair/replacement in the toddler daycare room for a missing sink stopper cover; repair/replacement in the infant daycare room for a properly fitted toilet tank cover; repair/replacement in the first-floor common bathroom for several holes in the walls. The Program Director received an update from the PHMC facilities Department that replacement and repairs for these items will be completed by 2/20/2026. Copies of the ticket and ticket completion report will be kept on file in the facilities ticketing database.
All staff and supervisors responsible for ensuring facility bathroom upkeep will be trained by the Program Director or the Program Director's Designee on the 705.6 (7) Bathrooms requirement and on this Plan of Correction by 2/27/2026. 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 2/27/2026. A copy of the training completion and staff participating will be kept on file in the staff members training files.
During regular (e.g. daily) facility checks, The 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 Program Director's designee for Facilities Management 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 office of the Program Director's designee for Facility Management. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
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705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor.
At the time of the inspection, there were multiple boxes of food stored and sitting on the floor of the kitchen pantry.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: On 1/13/2026, the Program Director and Residential Assistants removed stored food item boxes from the floor and placed them on shelves elevated above floor level.
All staff and supervisors responsible for ensuring food service will be trained by the Program Director or the Program Director's Designee on the 705.7 (b)(6) Food service requirements and on this Plan of Correction by 2/27/2026. The training will include that the residential facility that operates an onsite food preparation area or a central food preparation area shall store all food items off the floor. A copy of the training completion and staff participating will be kept on file in the staff members training files.
During regular (e.g. daily) facility checks, The Program Director's designee for Facilities Management will review that food service areas are kept according to 705.7 (b)(6) food service regulatory requirements and that staff are appropriately completing daily food service and storage tasks using the IHW RA daily facility and grounds checklist. The Program Director's designee for Facilities Management 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 office of the Program Director's designee for Facility Management. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all exits from rooms were unobstructed.
At the time of the inspection, bedroom 204 A/B swing and bedroom 201 A/B swing had clothing, toys, and other items blocking the exit doors.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: On 1/13/2026, the Program Director and Residential Assistants immediately removed clothing, toys, and other items blocking the exit doors, so that exits were cleared of fire safety obstructions.
All staff and supervisors responsible for ensuring fire safety will be trained by the Program Director or the Program Director's Designee on the 705.10 (a)(1)(i) fire safety requirements and on this Plan of Correction by 2/27/2026. The training will include that the residential facility shall Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed. A copy of the training completion and staff participating will be kept on file in the staff members training files.
During monthly fire drills and during regular (e.g. daily) facility checks, The Program Director's designee will review that stairways, hallways and exits from rooms and from the residential facility are unobstructed according to 705.10(a)(1)(i) fire safety regulatory requirements and that staff are appropriately completing monthly fire drill and daily facility and grounds tasks using the IHW fire drill log and the IHW RA daily facility and grounds checklist. The Program Director's designee will immediately oversee correction of any obstruction issues identified during the course of fire drills and facility checks. The Program Director's designee will report any identified and corrected 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 office of the Program Director's designee for Facility Management. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
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705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based on a physical plant inspection, the facility failed to maintain a smoke detector within 15 feet of each bedroom door.
At the time of the inspection, there was no smoke detector located within 15 feet of the doors to both bedroom 306A and bedroom 303A/B.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: On 1/22/2026, the PHMC Facilities Department replaced the smoke detection devices so that there was an operable smoke detector located within 15 feet of the doors to both bedroom 306A and bedroom 303A/B.
All staff and supervisors responsible for ensuring fire safety will be trained by the Program Director or the Program Director's Designee on the 705.10 (b)(2) fire safety requirements and on this Plan of Correction by 2/27/2026. The training will include that the residential facility shall, on floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door; On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway; All detection devices shall be interconnected. A copy of the training completion and staff participating will be kept on file in the staff members training files.
During monthly fire drills and during regular (e.g. daily) facility checks, The Program Director's designee will review that the residential facility is compliant with 705.10 (b)(2) fire safety regulatory requirements and that staff are appropriately completing fire drill logs and daily facility and grounds tasks using the IHW fire drill log and the IHW RA daily facility and grounds checklist. The Program Director's designee will immediately oversee immediate correction of any fire safety issues identified during the course of facility checks. The Program Director's designee for Facilities Management will report any identified and corrected issues to the Program Director for continued 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 office of the Program Director's designee for Facility Management. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
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705.11 (2) (ii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(ii) Maintain security screens or safety locks for all operable windows.
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Observations
Based on a physical plant inspection, the facility failed to maintain security screens or safety locks for all operable windows.
At the time of the inspection, there were broken window screens in bedroom 301A and the third-floor lounge. Additionally, there was a broken window latch in bedroom 301A/B swing, which had caused the windowpane to fall outside of the frame.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: The Program Director submitted a facilities ticket to the PHMC facilities department requesting replacement/repairs to broken window screens in bedroom 301A and in the third-floor lounge; replacement/repairs to a broken window latch and to a fallen windowpane in bedroom 301A/B swing. The Program Director received an update from the PHMC Facilities Department that replacement and repairs for these items will be completed by 2/20/2026. Copies of the ticket and ticket completion report will be kept on file in the facilities ticketing database.
All staff and supervisors responsible for ensuring upkeep of childcare interior spaces will be trained by the Program Director on the 705.11 (2)(ii) child care requirements and on this Plan of Correction by 2/27/2026. The training will include that the residential facility shall maintain security screens or safety locks for all operable windows. A copy of the training completion and staff participating will be kept on file in the staff members training files.
During regular (e.g. daily) facility checks, The Program Director's designee for Facilities Management will review that the residential facility is compliant with 705.11 (2)(ii) Child care regulatory requirements and that staff are appropriately completing daily facility and grounds tasks using the IHW RA daily facility and grounds checklist. The Program Director's designee for Facilities Management will immediately oversee correction of any issues identified during the course of facility checks. The Program Director's designee for Facilities Management will report any identified and corrected issues to the Program Director for continued 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 office of the Program Director's designee for Facility Management. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
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705.11 (2) (iii) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection, the facility failed to maintain protective caps over each electrical outlet.
At the time of the inspection, there were several outlets in multiple bedrooms and bathrooms, the common areas, and the daycare areas that did not have protective caps over each electrical outlet.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: The Program Director submitted a facilities ticket to the PHMC facilities department requesting replacements for protective caps on outlets in bedrooms and bathrooms, the common areas, and the daycare areas that did not have protective caps over each electrical outlet. The Program Director received an update from the PHMC Facilities Department that outlets with built-in safety outlet covers were installed and the ticket request completed on 1/29/2026. Copies of the ticket request and ticket completion report will be kept on file in the facilities ticketing database.
All staff and supervisors responsible for ensuring upkeep of childcare interior spaces will be trained by the Program Director or the Program Director's Designee on the 705.11 (2)(iii) child care requirements and on this Plan of Correction by 2/27/2026. The training will include that the residential facility shall maintain protective caps over each electrical outlet. A copy of the training completion and staff participating will be kept on file in the staff members training files.
During regular (e.g. daily) facility checks, The Program Director's designee for Facilities Management will review that the residential facility is compliant with 705.11 (2)(iii) Child care regulatory requirements and that staff are appropriately completing daily facility and grounds tasks using the IHW RA daily facility and grounds checklist. The Program Director's designee for Facilities Management will immediately oversee immediate correction of any electric outlet protective cap issues identified during the course of facility checks. The Program Director's designee for Facilities Management will report any identified and corrected issues to the Program Director for continued 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 office of the Program Director's designee for Facility Management. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
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705.11 (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.
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Observations
Based on a physical plant inspection, 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 unsecured located in bedroom 301A, bedroom 204A/B's bathroom, and next to the changing table in the toddler daycare room.
This is a repeat citation from the July 18, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Issues identified by the DDAP inspection were addressed as follows: On 1/13/2026 , The Program Director and Resident Assistants removed hazardous and poisonous substances and materials from unsecured areas located in bedroom 301A, bedroom 204A/B's bathroom, and next to the changing table in the toddler daycare room; and placed the items in locked storage closets where they could be retrieved and returned by adult clients and staff as needed. An internal facility inspection on 2/5/2026 confirmed that hazardous items were stored in locked location out of reach from children in the facility. A facility ticket was placed by the Program Director on 1/14/2026 for the following: installation of safety latched on unsecured bathroom vanities, including those in located in bedrooms 301A/B, and 204A/B. Expected completion of ticket items is 2/27/2026.
All staff and supervisors responsible for ensuring facility upkeep will be trained by the Program Director or the Program Director's Designee on the 705.11 (2)(iv) Child care requirement and on this Plan of Correction by 2/27/2026. 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 2/27/2026. A copy of the training completion and staff participating will be kept on file in the staff members training files.
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)(iv) child care regulatory requirements and that staff are appropriately completing daily tasks using the IHW RA daily facility and grounds checklist. The Program Director's designee for Facilities Management 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 office of the Program Director's designee for Facility Management. Copy of facilities ticket requests and a copies of the completion reports will be kept on file in the PHMC facilities database.
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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.
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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 the local police were onsite at the facility on October 10, 2025; however, there was no documentation showing the incident was reported to the Department at the time of the inspection.
This is a repeat citation from the July 18, 2025 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 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 2/27/2026. 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 2/27/2026, 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 or the Program Director's Designee, by 2/27/2026, and the plan will be fully implemented by 2/27/2026.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a physical plant inspection and a review of client records and the project's policy and procedure manual, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring the facility is in good repair at all times was submitted and approved by the Department for the February 6, 2024 provisional license follow-up inspection, July 24, 2024 annual licensing inspection, and July 18, 2025 annual licensing inspection. Failing to keep the facility in good repair at all times was again found to be a deficiency in the January 13, 2026 provisional license follow-up inspection.
A plan of correction for maintaining each bathroom in a functional, clean and sanitary manner at all times was submitted and approved by Department for the July 24, 2024 annual licensing inspection, and July 18, 2025 annual licensing inspection. Failing to maintain each bathroom in a functional, clean and sanitary manner at all times was again found to be a deficiency in the January 13, 2026 provisional license follow-up inspection.
This is a repeat citation from the July 24, 2024 and July 18, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors responsible for implementing Department approved plans of correction will be trained by the Program Director or the Program Director's Designee on the requirements of 709.17(a)(3) by 2/27/2026. 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 Program 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.
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.
All staff and supervisors responsible for implementing Department approved plans of correction will be trained by the Program Director or the Program Director's Designee on the requirements of 709.17(a)(3) by 2/27/2026, and the plan fully implemented by 2/27/2026.
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