INITIAL COMMENTS
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This report is a result of an part two licensing inspection conducted on February 11, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Interim House West was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 the physical plant inspection conducted on February 11, 2021, the facility failed to ensure the building was safe and in good repair.
Faucet located in the staff bathroom on the first floor within the admin area was detached from the sink.
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Plan of Correction
The maintenance assistant repaired the faucet on February 12, 2021 in staff bathroom on the first floor. Facility Manager will conduct an in-service training with staff and clients on repairing and completing the maintenance request form. Maintenance assistant will inspect and monitor all faucets weekly and provide weekly reports to facility manager to ensure all faucets are repaired and safe. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on the physical plant inspection conducted on February 11, 2021, the facility failed to ensure covering over one of their trash containers located in the rear of the facility.
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Plan of Correction
The maintenance assistance will inspect all trash containers daily to ensure that trash containers led is properly covered. The maintenance assistant will provide Facility Manager a daily update on trash containers. Facility Manager will continue to work closely with the independent sanitation company to ensure that all trash is remove twice a week. |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on the physical plant inspection conducted on February 11, 2021, the facility failed to furnish the bedrooms with bunkbeds with secure attached railings on each open.
Bedrooms located on the second and third floor
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Plan of Correction
The Bunk Beds railing was ordered on February 12, 2021 and was placed on bunk beds on 3/4/2021. Facility manager will monitor and track all bunk bed railings to ensure safety. The Residential assistant will inspect and monitor all clients bunk bed to ensure all bunk beds are securely attached. Residential Assistant will provide weekly reports to facility manager to ensure all railing are safe and secure. |
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 the physical plant inspection conducted on February 11, 2021, the facility failed to ensure the proper functioning of a toilet within a shared bathroom between rooms 203A and 203B.
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Plan of Correction
The maintenance assistant repaired the toilet within the shared bathroom 203A and 203B on February 11, 2021. Maintenance assistant will inspect all bathroom to ensure all toilets or working properly. Any toilet in disrepair will be replaced. on 3/3/2021 Facility Manager will hold a household management class with clients and the focused will be toilet repair, other repairs in clients living space, how to fill out a maintenance repair slip and verbally informing facility manager of any repairs in client's room/living space. Residential assistant will monitor client's room weekly for repair and place a work order slip for all repairs. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection conducted on February 11, 2021, the facility failed to display proper temperature reading within the refrigerator located in the staff lounge on the second floor.
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Plan of Correction
The maintenance assistant placed a thermometer in refrigerator located in the staff lounge on February 11, 2021. Thermometer in staff refrigerator will be inspected and recorded daily. Temperature check sheet will be placed in staff lounge for recording. |
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 the physical plant inspection conducted on February 11, 2021, the facility failed to maintain protective caps over electrical outlets.
and therapist offices located on the first floor
304A, 306A, 202B and 204B
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Plan of Correction
The maintenance assistant placed the protective caps in 304A, 306A, 202B and 204B on February 11, 2021. Protective cap was also placed in Family Service Coordinator offices located on first floor on February 11, 2021. 3/3/2021 Facility Manager will hold a household management class with clients and the focused will be understanding the important of maintaining protective caps over electrical outlets in your unit/room. The Residential assistant will inspect and monitor all client's electrical outlets in room to ensure the protective caps are in place. Residential Assistant will provide weekly reports to facility manager to ensure all protective caps are over electrical outlets in client's room. |
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 on February 24, 2021, the facility failed to document an informed and voluntary consent in five of ten client records.
Client #4 - consent to releases one dated 4/6/10 and the other 3/25/2020 for two different agencies did not have documentation that the client was offered a copy of either releases.
Client #6 - consent to releases dated 1/15/2021, 1/29/2021 for two agencies did not have documentation of the person to whom is for.
Consent to release dated 1/19/2021 for an agency did not have documentation that the client was offered a copy of their consent.
Client #7 - consent to releases both dated 10/2/2020 for two different agencies did not have documentation that the client was offered a copy of either releases.
Consent to release dated 10/2/2020 to an agency did not have the agency's name, what's being release and purpose for the release.
Email dated 10/2/2020 to an agency with identifying information about the client, but no consent to release for that agency documented in the client's record.
Client #9 - consent to release dated 7/16/2020 for an agency did not have documentation that the client was offered a copy of their consent.
Consent to release dated 10/2/2020 to an agency did not have the agency's name, what's being release and expiration date for the release.
Client #10 - consent to releases one dated 2/3/2021 and the other 2/4/2021 for two different agencies did not have documentation that the client was offered a copy of either releases.
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Plan of Correction
IHW Clinical Director and TQM manager will hold a staff training on confidentiality 3/10/2021 as it pertains to release of information, dates, expired dates, agency's names and offering the client a copy of the release (s). Training will be documented by signature of attendance sheets. All current release will be reviewed and updated to meet regulation.
All clients will be made aware of all consent forms that release or receive information as it pertains to their treatment. Each client will be offered a copy of the consent form and it will be documented if the client accepts or refuses a copy of the consent form. The consent form will be documented and filed.
Program Director will ensure that in-services training form is filed in training manual and chart.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records on February 11, 2021, the facility failed to include the following verbiage on the client rights form that the client signs, creed and ethnicity.
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Plan of Correction
Interim House West Program Director remove the old client right form and updated the form to include the following verbiage age, race, creed, sex ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion.
On 4/7/2021 all current participants met with case manager to review and resign the update Participant Civil Right Form.
During the admission process the Admission Coordinator will ensure that all participants has read and understand the client civil right form before the participant sign and Admission Coordinator sign as a witness. The Admission Coordinator will ask the participant if they would like a copy of the form. The assigned document will be filed in the participant chart.
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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 on February 11, 2021, the facility failed to document a notice of termination in two of five discharged records.
Client #4 was administratively discharged on 4/13/2029
Client #3 was administratively discharged on 11/6/2019
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Plan of Correction
All clients that enter Interim House West will obtain a Preliminary Aftercare/Discharge plan when entering treatment. Within the first seven days the preliminary aftercare plan will be completed, and Discharge/Aftercare Plan will be done upon discharge. The Aftercare/Discharge Plan will indicate the reason for discharge.
The Clinical Director will be responsible for conducting an in-service training by 3/9/2021 with all staff responsible for initiating and completing aftercare/discharge plans. Clinical Director will conduct audits to ensure that preliminary aftercare/discharge plan are completed in order to adhere to policy 709.33 Notification of termination.
Program Director will ensure that in-services training form is filed in training manual and chart audits are done.
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