INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2024 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure a written individual training plan for each employee was developed with input from both the employee and the supervisor in one of four personnel records reviewed.
Employee #4 was hired as a counselor on May 20, 2024. The individual training plan was completed by the counselor on May 20, 2024 and the supervisor signed the training plan on June 24, 2024. There was no documentation indicating that the individual training plan was developed with input from both the employee and supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director and Facility Director. All staff development plans are to be completed and signed by both staff and supervisor within the first 30 days of employment. Effective immediately, Project Transition will use progressive discipline if any staff fail to comply with completing and signing their staff development plan. This will be documented in supervision and will be reviewed and tracked by the Facility Director and Project Director. |
704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that their Partial Hospitalization activity had a minimum of one Full Time Equivalent (FTE) counselor providing counseling services for every ten clients.
The FTE is determined by dividing the total number of hours counselors devoted to their clients (36) by the project workweek (40) is 36/40 = .9. Then, to obtain the overall ratio, the total number of clients on the partial hospitalization caseload (12) is divided by the FTE (.9) is 12/.09 = 13.33 or 13/1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Transition has had a clinician that was part-time leave and has replaced that clinician with a full-time clinician. Upon entering the hours for that full-time clinician, we are now wtihin the allotted caseload. The Executive Director of Clinical will ensure our ratio stays 10:1 at a maximum.
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705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the facility's August 2023 through June 2024 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions.
The fire drill log for December 2023 documented that the fire drill was conducted at 12:05AM, which is outside of the facility's posted hours of operation of Monday through Sunday from 8:00AM to 9:00PM.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
After investigating, the time was mismarked. It should have read PM, not AM. This conclusion was reached due to no staff being onsite after 9pm to conduct a drill. Staff have been retrained on Fire Drills, specifically ensuring that drills are done within the office open hours. This training also included the importance of correct documentation. The Facility Director will sign off on all fire drills ensuring all documentation is correct.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's August 2023 through June 2024 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
There were eleven fire drills completed during the reviewed period and all of the drills were completed prior to 12:42PM. The facility's hours of operation were posted as 8:00AM to 9:00PM on Monday through Sunday. None of the fire drills reviewed were conducted during the evening and/or weekend hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Findings were reviewed with the Facility Director. Facility Director will immediately implement a rotating time of Fire Drills to encompass hours from 8am to 9pm. This will be verified through quality program audits every six weeks. |
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 an administrative review, 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 includes reference to the drug and alcohol treatment activities.
There was no financial audit completed for the reviewed timeframe. The project's last reviewed, annual financial audit was for the years ending December 31, 2020 and 2019.
This is a repeat citation from the September 29, 2022 and July 25, 2023 annual licensing renewal inspections.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The former Director of Finance is no longer with the company. A new VP of Finance has been hired and will ensure that audits are completed in a timely manner. The new VP of Finance is currently working with Dunlap SLK to get the past audits completed. This will be monitored by the Quality team and reviewed with the Finance team on a quarterly basis to ensure completion. |
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 review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days following an unusual incident involving the physical or sexual assault by staff or a client.
On May 6, 2024, the facility was notified by a client of a physical assault. There was no documentation that the incident was reported to the Department as of the date of the 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 and the Facility Director. A review of reportable incidents was completed with program staff. The Regional Director will ensure that any reportable incidents have been completed within 3 days of the incident occurring.
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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 client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in three of five applicable client records reviewed.
Client #3 was admitted into the partial hospitalization activity on March 18, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 18, 2024 and the first update was due no later than April 18, 2024; however, the update was completed on May 22, 2024. Additionally, the next treatment plan update was due no later than June 22, 2024; however, the update was completed on July 26, 2024.
Client #4 was admitted into the partial hospitalization activity on July 5, 2023 and was discharged on May 6, 2024. A treatment plan update was completed on September 18, 2024 and the next update was due no later than October 18, 2024; however, the update was completed on November 17, 2023. Additionally, the next treatment plan update was due no later than December 17, 2023; however, the update was completed on December 29, 2023.
Client #5 was admitted into the partial hospitalization activity on October 3, 2023 and was discharged on January 5, 2024. The individual treatment and rehabilitation plan was completed on October 3, 2023 and the first update was due no later than November 3, 2023; however, the update was completed on December 27, 2023.
Client #6 was admitted into the partial hospitalization activity on November 22, 2023 and was discharged on March 28, 2024. A treatment plan update was completed on December 18, 2023 and the next update was due no later than January 18, 2024; however, the update was completed on February 26, 2024.
Client #7 was admitted into the partial hospitalization activity on May 26, 2023 and was discharged on March 11, 2024. A treatment plan update was completed on October 3, 2023 and the next update was due no later than November 3, 2023; however, the update was completed on December 4, 2023.
This is a repeat citation from the July 25, 2023 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, 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. Additonaly, the quality team has implemented a due date in the internal audit sheet. This information will be reviewed in a weekly meeting with the Facility Director, Project Director and Clinical Supervisor. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client #4 was admitted into the partial hospitalization activity on July 5, 2023 and was discharged on May 6, 2024. The treatment plan update dated March 4, 2024 indicated individual counseling services twice per week. There was documentation, in the record, of one individual counseling service occurring during the weeks of March 10, 2024 through March 16, 2024 and March 17, 2024 through March 23, 2024.
Client #5 was admitted into the partial hospitalization activity on October 3, 2023 and was discharged on January 5, 2024. The treatment plan update dated December 27, 2023 indicated individual counseling services twice per week. There was no documentation, in the record, of individual counseling services occurring during the week of December 10, 2023 through December 16, 2023. Additionally, there was documentation, in the record, of one individual counseling session occurring during the weeks of December 17, 2023 through December 23, 2023 and December 24, 2023 through December 30, 2023.
Client #6 was admitted into the partial hospitalization activity on November 22, 2023 and was discharged on March 28, 2024. The individual treatment and rehabilitation plan and treatment plan updates dated November 22, 2023, December 18, 2023, and February 26, 2024 indicated individual counseling services twice per week. There was documentation, in the record, of one individual counseling session occurring during the weeks of November 26, 2023 through December 2, 2023, December 10, 2023 through December 16, 2023, December 17, 2023 through December 23, 2023, February 25, 2024 through March 2, 2024, March 3, 2024 through March 9, 2024, and March 17, 2024 through March 23, 2024. Additionally, there was no documentation, in the record, of individual counseling sessions occurring during the week of December 3, 2023 through December 9, 2023.
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, the Facility Director and the National Clinical Director. Project Transition has re-trained the clinical team on the importance of having the Treatment Plan include the correct services provided. The clinicians and teams have also been reminded to ensure that the services listed are in fact being provided. Additonally, the quality team has implemented a due date in the internal audit sheet. This information will be reviewed in a weekly meeting with the Facility Director, Project Director and Clinical Supervisor. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on review of client records, the facility failed to assure that clients admitted to the partial hospitalization program received the required individual counseling services of at least twice weekly in three of seven client records.
Client #4 was admitted into the partial hospitalization activity on July 5, 2023 and was discharged on May 6, 2024. There was documentation, in the record, of one individual counseling session occurring during the weeks of March 10, 2024 through March 16, 2024 and March 17, 2024 through March 23, 2024.
Client #5 was admitted into the partial hospitalization activity on October 3, 2023 and was discharged on January 5, 2024. There was documentation, in the record, of one individual counseling session occurring during the weeks of December 17, 2023 through December 23, 2023 and December 24, 2023 through December 30, 2023.
Client #6 was admitted into the partial hospitalization activity on November 22, 2023 and was discharged on March 28, 2024. There was documentation, in the record, of one individual counseling session occurring during the weeks of November 26, 2023 through December 2, 2023, December 10, 2023 through December 16, 2023, December 17, 2023 through December 23, 2023, February 25, 2024 through March 2, 2024, March 3, 2024 through March 9, 2024, and March 17, 2024 through March 23, 2024. Additionally, there was no documentation, in the record, of no individual counseling sessions occurring during the week of December 3, 2023 through December 9, 2023.
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, the Facility Director and the National Clinical Director. Project Transition will re-train the clinical team on the importance of having both sessions every week by 9/15/24. The Quality Department will audit on a monthly basis to ensure all sessions are being documented. The National Clinical Director will ensure all sessions are documented properly. |
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 maintain a complete client record, which is to include follow-up information, in two of four applicable client records reviewed.
Client #5 was admitted into the partial hospitalization activity on October 3, 2023 and was discharged on January 5, 2024. There was no documentation of follow-up information in the record at the time of inspection.
Client #6 was admitted into the partial hospitalization activity on November 22, 2023 and was discharged on March 28, 2024. There was no documentation of follow-up information in the record at the time of 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 added Discharge Follow Up to the KPIs, which will be monitored a minimum of monthly by the Facility Director. The Regional Operations Director will ensure that follow up documentation is being completed. In addition re-training regarding member documentation will be completed, which will include review of process maps and deadlines.
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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 review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to complete an annual financial audit was submitted and approved by the Department for the September 29, 2022 and July 25, 2023 annual licensing inspections. Not completing an annual financial audit was again found to be a deficiency in the July 23, 2024, annual licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Since the last audit, Project Transition has revamped its Senior Leadership Team. This re-arrangement included a new President, VP of Finance, VP of Program Operations and a National Clinical Director. Each Corrective Action Plan is reviewed by the President, VP of Outcomes, VP of Program Operations and the National Clinical Director to ensure that the plan is able to be accomplished. The Corrective Action Plan will also have a review of 30, 60 and 90 days to ensure the plan has corrected the items. The VP of Outcomes will ensure that this is completed and the results will be reported to the entire Senior Leadership Team. The 30 day review of the CAP will be completed by 10/7/24.
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