INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Project Transition 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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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.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent to release information form was offered to the client in three of seven client records reviewed.
Client #1 was admitted on July 15, 2021 and was active at the time of inspection. Release of information forms to a pharmacy, a funding source and an emergency contact were signed and dated by the client on July 15, 2021 and there was no documentation that copies of any of the release forms were offered to the client.
Client #2 was admitted on April 1, 2021 and was active at the time of inspection. Release of information forms to a pharmacy and an emergency contact were signed and dated by the client on April 1, 2021 and there was no documentation that copies of either release form were offered to the client.
Client #6 was admitted on March 4, 2021 and was discharged on June 16, 2021. Release of information forms to a funding source, a pharmacy and an emergency contact were signed and dated by the client on March 4, 2021 and there was no documentation that copies of any of the release forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director and the Facility Director. Based on the review of these findings, all current Member's consents were updated with the updated version of the consent that includes asking the Member if they have been offered a copy. Project Transition has re-designed the consent. The consent was updated and now includes a place where the Member can check if they have been offered a copy. The Facility Director will ensure consents are completed for all Members.
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to include documentation of a completed psychosocial evaluation in their intake and admission process in one of three applicable client records reviewed.
Client #2 was admitted on April 1, 2021 and was active at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director, Facility Director and the Clinical Director. Upon closer review, Client #2 did have a biopsychosocial completed upon admission. However, Project Transition still held a training on 9/30/21 to re-train all clinicians to ensure that a psychosocial evaluation within their Biopsychosocial Assessment. The VP of Clinical will ensure that all admissions include a psychosocial evaluation.
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709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in the client's comprehensive treatment plan in one of three applicable client records reviewed.
Client #2 was admitted on April 1, 2021 and was active at the time of inspection. The individual treatment and rehabilitation plan for the client did not include documentation of the type and frequency of services to be provided.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director, Facility Director and the Clinical Director. Based on the review of these findings, Project Transition held a training on 9/30/21 to re-train all clinicians to ensure that the type and frequency needs to be on the Care Plan. Care Plans were updated for each Member, including Client #2, to include the type and frequency of treatment. The VP of Clinical will ensure that all Care Plans include the time and frequency of treatment. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which includes follow-up information, in four of four applicable client records reviewed.
Client #4 was admitted on February 27, 2020 and was discharged on March 15, 2021. There was no follow-up information documented at the time of the inspection.
Client #5 was admitted on September 12, 2019 and was discharged on April 23, 2021. There was no follow-up information documented at the time of the inspection.
Client #6 was admitted on March 4, 2021 and was discharged on June 16, 2021. There was no follow-up information documented at the time of the inspection.
Client #7 was admitted on November 12, 2019 and was discharged on June 25, 2021. There was no follow-up information documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director and the Facility Director. To prevent this issue from occurring in the future, Project Transition re-implemented a Quality Review at the program level on 6/1/21, which includes monitoring Follow Up documentation for all Members. The Regional Director will ensure that follow up documentation is being completed.
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