INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25, 2023, 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, Inc. 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and a discussion with facility staff, the facility failed to present the plan documenting the qualifications and training of staff during the time of the project ' s site visit. The plan presented at the time of the onsite visit did not accurately reflect staff positions, and a discussion with staff revealed that a staff member listed as a counselor had been acting as a clinical supervisor since prior to the September 29, 2022 annual licensing inspection, however, their credentials and experience had not been reviewed by the Department for the clinical supervisor qualifications.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Transition has created their own staffing requirements document that will be kept up to date by the Quality Team. This will be updated as staff is being hired or is terminated. This will allow for it to always be up to date and be submitted timely to DDAP. The Project Director will ensure compliance with all documentation needed to align with the staffing requirements on a quarterly basis. |
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.
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Observations
Based on a review of personnel records and a discussion with facility staff, the facility failed to provide documentation that the clinical supervisor participated in monthly meetings with their supervisor for the first six months of employment in one applicable record reviewed.
Employee # 3 was promoted to clinical supervisor on March 17, 2022. Although this employee ' s date of promotion was prior to the previous inspection, they were not identified as a clinical supervisor during the previous inspection, thus their credentials were not reviewed. No supervision meetings were documented for the employee ' s first six months of employment.
This is a repeat citation from the September 29, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Transition's Clinical Supervisor did not have supervision notes. We do have a new Executive VP of Clinical and Program Operations. She will ensure that notes are taken during supervision. Project Transition has created a new KPI document that looks at supervision at least monthly and is tracked by the Project Director on a monthly basis. This will be monitored and reviewed by the Quality Team quarterly. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on July 25, 2023, the facility failed to ventilate bathrooms by exhaust fan or window. The restroom down the second hallway to the left of the main entrance did not have ventilation by an exhaust fan or a window.
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. Based on the review of these findings our Director of Facilities ensured that the fan was installed in the bathroom. To prevent this issue from occurring in the future, the Facility Director will use the Office Checklist to ensure each bathroom has a working exhaust fan. This office checklist will be completed on a monthly basis. The Project Director will monitor and ensure these are completed on a quarterly basis.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents submitted, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project's last annual financial audit was for the years ending December 31, 2020 and 2019.
This is a repeat citation from the September 29, 2022 annual licensing renewal inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The former Director of Finance is no longer with the company. The financial audit for this year has been started (by an independent certified accountant) and should be completed by 9/30/23. A new Director of Finance has been hired and will ensure that audits are completed in a timely manner. This will be monitored by the Quality team and reviewed with the Finance team on a quarterly basis to ensure completion. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, in one of three applicable personnel records reviewed.
Employee # 3 has been in the clinical supervisor position since March 17, 2022. There was no annual performance evaluation documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed by the Facility Director, Project Director and the VP of Human Resources. The Facility Directors will monitor and complete annual performance evaluations for all employees on an annual basis. The annual performance review was added to the new supervision and KPI document that is completed on a monthly basis. The Project Director will ensure these documents are completed on a quarterly basis. |
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 seven client records, the facility failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in one record reviewed.
Client # 4 was admitted to the partial hospitalization level of care on March 16, 2022 and was discharged on March 27, 2023. There was an informed and voluntary consent form to the funding source, signed and dated by the client on March 16, 2022, which expired on March 16, 2023. There was documentation of billing after the expiration date and there was no updated consent form signed by the client documented in the record prior to the disclosures.
This is a repeat citation from the September 29, 2022 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director and Facility Director. Within the new Electronic Health Record, the form was re-built with the next one scheduled. This schedule consent will automatically come up on the list of due items for the staff. The Project Director will ensure all consents are fill out completely and correctly for all Members. |
709.82(a) 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:
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Observations
Based on a review of seven client records and the policies and procedures of the facility, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client on the day of admission, per the facility policy, in two of five applicable records reviewed.
Client # 1 was admitted on March 6, 2023 and was discharged on May 17, 2023. The individual treatment and rehabilitation plan was due to be completed by March 6, 2023; however, the record contained no documentation that the plan was completed prior to the client ' s discharge.
Client # 6 was admitted on November 25, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by November 25, 2022; however, the plan was not completed until January 31, 2023.
The 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, the Facility Director and the Clinical Supervisor. Project Transition has re-trained the clinical team on the importance of having the Treatment Plan completed upon admission. The Quality Department will audit on a weekly basis to ensure all Member has a current Treatment Plan. This information will be reviewed in a weekly meeting with the Facility Director, Project Director and Clinical Supervisor. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in five of six applicable records reviewed.
Client # 2 was admitted on July 25, 2022 and was discharged on May 27, 2023. A treatment plan update was completed on October 24, 2022, and the next treatment plan update was due no later than November 24, 2022; however, the next update was not completed until February 15, 2023. The subsequent treatment plan update was due to be completed by March 15, 2023; however, the plan was not completed until April 14, 2023.
Client # 3 was admitted on October 18, 2022 and was discharged on July 1, 2023. The treatment and rehabilitation plan was completed on October 19, 2022, and the treatment plan update was due no later than November 19, 2022; however, the update was not completed until March 29, 2023. The subsequent treatment plan update was due to be completed by April 29, 2023; however, the record contained no additional treatment plan updates prior to the client ' s discharge.
Client # 4 was admitted on March 16, 2022 and was discharged on March 27, 2023. A treatment plan update was completed on October 24, 2022 and the next treatment plan update was due to be completed by December 24, 2022; however, the record contained no additional treatment plan updates prior to the client ' s discharge.
Client # 5 was admitted on April 26, 2023 and was active at the time of the inspection. The treatment and rehabilitation plan was completed on April 28, 2023, and the treatment plan update was due no later than May 28, 2023; however, the update was not completed until July 6, 2023.
Client # 6 was admitted on November 25, 2022 and was active at the time of the inspection. The treatment and rehabilitation plan was completed on January 31, 2023, and the treatment plan update was due no later than March 2, 2023; however, the update was not completed until March 14, 2023. The subsequent treatment plan update was due to be completed by April 14, 2023; however, the update was not completed until May 17, 2023. The following treatment plan update was due to be completed by June 17, 2023; however, it was not completed until July 5, 2023.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
These findings were reviewed with the Project Director, the Facility Director and the Clinical Supervisor. Project Transition has re-trained the clinical team on the importance of having the Treatment Plan completed every 30 days. The Quality Department will audit on a weekly basis to ensure all Member has a current Treatment Plan. This information will be reviewed in a weekly meeting with the Facility Director, Project Director and Clinical Supervisor.
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709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of seven client records and the facility ' s policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every 60 days, per the facility ' s policy, in five of six applicable records reviewed.
Client # 2 was admitted on July 25, 2022 and was discharged on May 27, 2023. A case consultation was documented on October 19, 2022, and the next consultation was due to be completed by December 19, 2022; however, it was not completed until January 31, 2023. The subsequent case consultation was due to be completed by March 31, 2023; however, no additional case consultation notes were completed prior to the client ' s discharge.
Client # 3 was admitted on October 18, 2022 and was discharged on July 1, 2023. The client record did not contain documentation of case consultation notes.
Client # 4 was admitted on March 16, 2022 and was discharged on March 27, 2023. A case consultation was documented on August 23, 2022, and the next consultation was due to be completed by October 23, 2022; however, it was not completed until February 14, 2023.
Client # 5 was admitted on April 26, 2023 and was active at the time of the inspection. A case consultation was documented on May 2, 2023, and the next consultation was due to be completed by July 2, 2023; however, no additional case consultations were completed prior to the inspection.
Client # 6 was admitted on November 25, 2022 and was active at the time of the inspection. The client record did not contain documentation of case consultation notes.
This is a repeat citation from the September 29, 2022 annual licensing renewal 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, Facility Director and Clinical Supervisor. Project Transition will add the Big Team (Case Consult) to the weekly auditing tool that is reviewed with the Project Director, Facility Director and Clinical Supervisor. The Project Director will ensure that these are completed every 60 days. |
709.83(a)(6) 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in one of two applicable records reviewed.
Client # 4 was admitted on March 16, 2022 and was discharged on March 27, 2023. The client record did not contain documentation of a completed aftercare plan.
This is a repeat citation from the September 29, 2022 annual licensing renewal 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 an the Facility Director. Based on the review of these findings, to prevent this issue from occurring in the future, Project Transition is adding the completion of the After Care Plan (APPLE - Plan) to the Social Worker's KPI Supervision Document. The APPLE Plan has also added to the audit document that is reviewed on a weekly basis with the Facility Director and Project Director. The Project Director will ensure that each Member who leave the program has a completed After Care Plan.
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709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary, in two of four applicable records reviewed.
Client # 2 was admitted on July 25, 2022 and was discharged on May 27, 2023. The client record did not contain documentation of a completed discharge summary.
Client # 4 was admitted on March 16, 2022 and was discharged on March 27, 2023. The client record did not contain documentation of a completed discharge summary.
This is a repeat citation from the September 29, 2022 annual licensing renewal 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 an the Facility Director. Based on the review of these findings, to prevent this issue from occurring in the future, Project Transition is adding the completion of the Discharge Summary (APPLE - Leave) to the Social Worker's KPI Supervision Document. The APPLE Plan (including the discharge summary) has also added to the audit document that is reviewed on a weekly basis with the Facility Director and Project Director. The Project Director will ensure that each Member who leave the program has a completed the Discharge Plan. |