INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and provisional license follow-up inspection conducted on July 14, 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.
At the time of the inspection, there were broken and sharp-edged window frames in rooms 306 A and 204. Also, there were broken floor tiles in the swing room, which is between rooms 201 and 201 B. Additionally, there was an active water leak as evidenced by the water-soaked ceiling tiles in the basement.
This is a repeat citation from the February 6, 2024 provisional license follow-up inspection, the July 24, 2024 and July 18, 2025 annual licensing renewal inspections, and the January 13, 2026 provisional license follow-up 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 the day of the inspection, the Program Director submitted facilities' tickets to the PHMC Facilities Department requesting repair and replacement of the broken and sharp-edged window frames in rooms 306A and 204, replacement/repair of the broken floor tiles in the swing room between rooms 201 and 201B, and investigation and repair of the active water leak evidenced by water-soaked ceiling tiles in the basement. Repairs on issues identified by the inspection were completed on 7/16/2026. All staff and supervisors responsible for facility upkeep will be trained by the Program Director or designee on 705.2(2) requirements for Building exterior and grounds and on this Plan of Correction by 8/31/2026. During daily facility inspections, the Program Director's designee for Facilities Management will review compliance and submit corrective actions as needed. Copies of facilities tickets and completion reports will be maintained in the facilities database. |
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 clogged sinks in client bathroom 202 A/B and 204 A/B and a clogged toilet in client bathroom 201 A/B. Also, there was a missing light cover in client bathroom 306 A/B and a portion of a baseboard missing in client bathroom 204A/B. Additionally, there was a rusted bathtub and a damaged wall in client bathroom 203 A/B, as well as a damaged wall and evidence of a previous leak in client bathroom 205 A/B.
This is a repeat citation from the July 24, 2024 and July 18, 2025 annual licensing renewal inspections and the January 13, 2026 provisional license follow-up 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: The Program Director submitted a facilities ticket requesting repair of clogged sinks in bathrooms 202A/B and 204A/B, repair of the clogged toilet in bathroom 201A/B, replacement of the missing light cover in bathroom 306A/B, replacement of the missing baseboard in bathroom 204A/B, repair or replacement of the rusted bathtub and damaged wall in bathroom 203A/B, and repair of the damaged wall and leak evidence in bathroom 205A/B. Repairs will be completed by 8/31/2026. All staff responsible for bathroom maintenance will receive training on 705.6(7) and this Plan of Correction by 8/31/2026. Daily facility rounds will include bathroom inspections and documentation of corrective actions. Copies of facilities tickets and completion reports will be maintained in the facilities database. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection, the facility failed to ensure the premises was free of rodent and insect infestation.
At the time of the inspection, there were what appeared to be fruit flies or gnats flying throughout the facility. Additionally, there were several dead cockroaches and water bugs on the floor in the basement pantry.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director contacted the contracted pest control provider for immediate inspection and treatment related to fruit flies, gnats, cockroaches, and water bugs observed during inspection. The facility will follow all recommended extermination and prevention measures, and service documentation will be maintained on file. All staff will be trained by 8/31/2026 on 705.9(1) requirements regarding maintaining a facility free of rodent and insect infestation. During daily facility inspections, staff will monitor and document signs of infestation and report concerns immediately to the Program Director or the Program Director's designee. Copies of facilities tickets and completion reports will be maintained in the facilities database. |
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 ripped and torn window screens located in room 301 B, 202 A, the swing room between 201 A and B, and the swing room between 306 A and B.
This is a repeat citation from the January 13, 2026 provisional license follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director submitted a facilities ticket requesting replacement of ripped and torn window screens located in room 301B, room 202A, the swing room between 201A and B, and the swing room between 306A and B. Repairs are scheduled for completion by 8/31/2026. Staff responsible for facility and window-lock safety will be trained on 705.11(2)(ii) and this Plan of Correction by 8/31/2026. Daily inspections will include verification that all operable windows maintain intact screens and safety devices. Staff will report concerns immediately to the Program Director or the Program Director's designee for follow-up. Copies of facilities tickets and completion reports will be maintained in the facilities database. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in two of three applicable client records reviewed.
The facility policy and procedure manual stated the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice.
Client # 5 was admitted on May 19, 2026 and was discharged against medical advice on May 21, 2026. There was no documentation in the record indicating the emergency contact was notified of the client's discharge at the time of the inspection.
Client # 6 was admitted on April 7, 2026 and was discharged against medical advice on June 1, 2026. There was no documentation in the record indicating the emergency contact was notified of the client's discharge at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Director reviewed records of Active Clients and implemented corrective measures to ensure emergency contacts are identified and will be notified within 12 hours of AMA discharge as required by facility policy. Clinical Staff were retrained on documentation requirements and a discharge checklist was revised to include verification of emergency contact notification. All clinical staff will be trained by the Program Director or designee training on 709.24(a)(3) and this Plan of Correction by 8/31/2026. Compliance Department will review discharge documentation during routine (eg twice annually) chart audits and will report any concerns to the Program Director and Clinical Director for follow-up. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 6 was admitted on April 7, 2026 and was discharged on June 1, 2026. There was evidence of disclosures to an outside caseworker on June 2, 2026; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Director reviewed the confidentiality incident and re-educated staff regarding the requirement to obtain a properly executed informed consent prior to disclosure of information. The Clinical Director will conduct a review of Active client records to ensure that Releases of Information and valid and present for all known 3rd parties. Client record audit tools were revised to verify the presence of signed consent forms before information is released. All staff handling confidential information will be trained on 709.28(c) and this Plan of Correction by the Program Director or the Program Director's designee by 8/31/2026. Supervisory chart reviews will monitor ongoing compliance. Compliance Department will review release of information documentation during routine (eg twice annually) chart audits and will report any concerns to the Program Director for follow-up. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, with the reason for termination being included in the written notification, in one of one applicable client record reviewed.
Client #4 was admitted on January 30, 2026 and was administratively discharged on March 5, 2026. There was 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; however, the reason for termination was not documented in the notification letter.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director revised the involuntary termination notification process with the Clinical Director to ensure all written termination letters include the specific reason for termination. Staff were instructed on regulatory requirements and documentation standards. All clinical and supervisory staff will be trained on 709.33(a) and this Plan of Correction by the Program Director or the Program Director's designee by 8/31/2026. Compliance Department will review documentation of notification of involuntary discharges during routine (eg twice annually) chart audits and will report any concerns to the Program Director for follow-up.
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709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on an administrative review, the facility failed to notify the Department within 3 business days following an unusual incident involving the physical or sexual assault by a staff or a client.
At the time of the inspection, there was documentation indicating there were several physical assault incidents by clients on March 27, 2026, April 28, 2026, May 4, 2026, and May 8, 2026; however, there was no documentation showing any of the incidents were reported to the Department.
These findings were 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)(1) Reporting of Unusual Incidents and this Plan of Correction by the Program Director or the Program Director's designee by 8/31/2026. Training will include the requirement to submit written unusual incident reports to DDAP within three business days following physical or sexual assaults involving staff or clients. The Program Director or the Program Director's designee will oversee submission of future reports and maintain reporting logs. Compliance Department will review documentation of notification of incidents to the Department during routine (eg twice annually) chart audits and will report any concerns to the Program Director for follow-up. |
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.
At the time of the inspection, there was documentation indicating police, fire, or ambulance personnel were onsite at the facility on January 23, 2026, January 30, 2026, February 14, 2026, February 17, 2026, February 27, 2026, March 2, 2026, March 5, 2026, March 10, 2026, March 29, 2026, April 13, 2026, May 19, 2026, May 27, 2026, June 1, 2026, and June 25, 2026; however, there was no documentation showing any of the incidents were reported to the Department.
This is a repeat citation from the July 18, 2025 annual licensing renewal inspection and January 13, 2026 provisional license follow-up inspection.
These findings were 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 this Plan of Correction by the Program Director or the Program Director's designee by 8/31/2026. Training will include reporting of events requiring police, fire, or ambulance personnel within three business days. The Program Director or the Program Director's designee will be responsible for ensuring timely submission of reports through the approved reporting system. Compliance Department will review documentation of notification of incidents to the Department during routine (eg twice annually) chart audits and will report any concerns to the Program Director for follow-up. |
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, a review of client records, and a review of 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 failing to ensure 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, July 18, 2025 annual licensing inspection, and January 13, 2026 provisional license follow-up inspection. Failing to maintain the facility in good repair at all times was again found to be a deficiency in the July 14, 2026 provisional license follow-up and annual licensing inspection.
A plan of correction for failing to maintain each bathroom in a functional, clean and sanitary manner at all times was submitted and approved by the Department for the July 24, 2024 annual licensing inspection, July 18, 2025 annual licensing inspection, and January 13, 2026 provisional license follow-up 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 July 14, 2026 provisional license follow-up and annual licensing inspection.
A plan of correction for failing to report an unusual incident event within 3 business days was submitted and approved by the Department for the July 18, 2025 annual licensing inspection, and the January 13, 2026 provisional license follow-up inspection. Failing to report an unusual incident event within 3 business days was again found to be a deficiency in the July 14, 2026 provisional follow-up and annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors responsible for implementing Department-approved Plans of Correction will be trained on 709.17(a)(3) and this Plan of Correction by the Program Director or the Program Director's designee by 8/31/2026. Supervisors will review the status of Plans of Correction for which they and their staff are responsible for implementation during regular (e.g. monthly) supervision sessions and document progress. The Program Director will review the status of implementation of Department Approved Plans of Correction with the PHMC Managing Director of Mental Health Services during regular (e.g. monthly) Program Director supervision meetings.
The PHMC Compliance Department will review status of implementation of Plans of Correction approved by the Department during routine (eg twice annually) audits and will report any concerns to the Program Director for follow-up.
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