INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6-7, 2012 by staff from the Division of Drug and Alcohol 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of personnel records, the facility failed to document feedback on completed training.
The findings include:
On August 6, 2012 one personnel record requiring documentation of feedback on completed training was reviewed, specifically record # 1. Personnel record # 1 did not contain documentation of feedback on completed training.
Personnel # 1 completed 16.5 clock hours of training during the 2011-2012 training year, but personnel #1 ' s record did not contain documentation of feedback on the trainings completed during the 2011-2012 training year.
The findings were confirmed by the Director of Quality Improvement on August 6, 2012.
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Plan of Correction
Being immediately Project Transition staff will be required to submit training feedback forms on all trainings they attend. This will be monitored and tracked by the Project Director |
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 the review of personnel records, the facility failed to document an individual training plan for each employee.
The findings include:
Six personnel records requiring an individual training plan were reviewed on August 6, 2012, specifically records # 1, 2, 3, 4, 5 and 6. The facility did not document an individual training plan in personnel records # 3 and 4.
Personnel # 3 was hired for his current position on 4/1/12. Personnel # 3 did not have a training plan for the current training year. The training plan in personnel # 3 ' s record was dated 11/1/10 and was for the 2010-2011 training year.
Personnel # 4 was hired for his current position on 4/1/12, but personnel #4 ' s record did not contain a training plan.
The findings were confirmed by the Director of Quality Improvement on August 6, 2012.
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Plan of Correction
Affective immediately staff will fill out a staff development plan with in the first 30 days of employment, this will be monitored and tracked by the HR department
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705.21 (2) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(2) Have a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
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Observations
Based on a review of administrative records, the facility failed to acquire a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
The findings include:
On August 6, 2012, the facility ' s administrative records were reviewed for documentation of a certificate of occupancy. The facility did not have a certificate of occupancy available for review.
The findings were confirmed by the Director of Quality Improvement on August 6, 2012.
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Plan of Correction
The Director or Quality Improvement will work with the city of Philadelphia and the Landlord of the Greenbriar program to receive an updated Certificate of Occupancy. The Director of Quality Improvement will submit the updated Certificate of Occupancy to the department by 10/1/2012 |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment.
The findings include:
Five personnel records requiring documentation of fire extinguisher training were reviewed on August 6, 2012. The facility did not document that fire extinguisher training was provided upon employment in personnel records # 3, 4, 5 and 6.
Employee # 3 was hired for his current position on 4/1/12, but verification of fire extinguisher training was not documented at the time of review on 8/6/12.
Employee # 4 was hired for his current position on 4/1/12, but verification of fire extinguisher training was not documented at the time of review on 8/6/12.
Employee # 5 was hired for his current position on 4/2/12, but verification of fire extinguisher training was not documented at the time of review on 8/6/12.
Employee # 6 was hired for his current position on 7/5/12, but verification of fire extinguisher training was not documented at the time of review on 8/6/12.
The findings were confirmed by the Director of Quality Improvement on August 6, 2012.
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Plan of Correction
Beginning immediately staff will receive fire extinguisher training with in the first week of employment. This will be documented on a check list in staff personnel files. The Director of Quality Improvement will audit the personnel files to verify that the training is taking place |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to ensure that all personnel are trained to perform assigned tasks during emergencies.
The findings include:
Five personnel records requiring documentation of emergency training were reviewed on August 6, 2012. The facility did not document that emergency training was provided to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Four out of the five records reviewed did not contain documentation that the employee had been trained to perform assigned task during emergencies, specifically in personnel records # 3, 4, 5 and 6.
Employee # 3 was hired for his current position on 4/1/12, but verification of emergency training was not documented at the time of review on 8/6/12.
Employee # 4 was hired for his current position on 4/1/12, but verification of emergency training was not documented at the time of review on 8/6/12.
Employee # 5 was hired for his current position on 4/2/12, but verification of emergency training was not documented at the time of review on 8/6/12.
Employee # 6 was hired for his current position on 7/5/12, but verification of emergency training was not documented at the time of review on 8/6/12.
The findings were confirmed by the Director of Quality Improvement on August 6, 2012.
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Plan of Correction
Beginning immediately staff will receive site specific emergency training with in the first week of employment. This will be documented on a check list in staff personnel files. The Director of Quality Improvement will audit the personnel files to verify that the training is taking place. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document medical histories.
The findings include:
Five client records requiring medical histories were reviewed on August 7, 2012, specifically records # 1, 2, 3, 4 and 5. The facility did not document a medical history within 30 days, as per facility policy, in records # 1, 2, 3, 4 and 5.
Client #s 1, 2, 3, 4 and 5 were all admitted to the facility ' s Addiction Recovery Track on 4/1/12, but medical histories had not been completed at the time of review on 8/7/12.
The findings were confirmed by the Director of Quality Improvement on August 7, 2012.
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Plan of Correction
Starting immediately Members whom are admitted to or transfer into Project Transitions Drug and Alcohol program will have a medical history completed within 30 days of the admission or transfer beginning immediately. The Quality Department of Project Transition will Audit members clinical charts to verify that medical history is being completed within the time frame. The Director of Quality Improvement will also conduct a full training on the documentation required when a member is admitted to or transferred into Project Transitions Drug and Alcohol program. |
709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document drug and alcohol histories.
The findings include:
Five client records requiring drug and alcohol histories were reviewed on August 7, 2012, specifically client records # 1, 2, 3, 4 and 5. The facility did not document a drug and alcohol history within 30 days, as per facility policy, in client records # 1, 2, 3, 4 and 5.
Client #s 1, 2, 3, 4 and 5 were all admitted to the facility ' s Addiction Recovery Track on 4/1/12, but drug and alcohol histories had not been completed at the time of review on 8/7/12.
The findings were confirmed by the Director of Quality Improvement on August 7, 2012.
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Plan of Correction
Starting immediately Members whom are admitted to or transfer into Project Transitions Drug and Alcohol program will have a drug and alcohol history completed within 30 days of the admission or transfer beginning immediately. The Quality Department of Project Transition will Audit members clinical charts to verify that the drug and alcohol history is being completed within the time frame. The Director of Quality Improvement will also conduct a full training on the documentation required when a member is admitted to or transferred into Project Transitions Drug and Alcohol program |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document personal histories.
The findings include:
Five client records requiring personal histories were reviewed on August 7, 2012, specifically client records # 1, 2, 3, 4 and 5. The facility did not document a personal history within 30 days of admission, as per facility policy, in client records # 1, 2, 3, 4 and 5.
Client #s 1, 2, 3, 4 and 5 were all admitted to the facility ' s Addiction Recovery Track on 4/1/12, but personal histories had not been completed at the time of review on 8/7/12.
The findings were confirmed by the Director of Quality Improvement on August 7, 2012.
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Plan of Correction
Starting Immediately Members whom are admitted to or transfer into Project Transitions Drug and Alcohol program will have a personal history completed within 30 days of the admission or transfer beginning immediately. The Quality Department of Project Transition will Audit members clinical charts to verify that the personal history is being completed within the time frame. The Director of Quality Improvement will also conduct a full training on the documentation required when a member is admitted to or transferred into Project Transitions Drug and Alcohol program |
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 the review of client records, the facility failed to document treatment plan updates that included an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan in five of five client records.
The findings include:
Five client records requiring treatment plan updates were reviewed on August 7, 2012, specifically client records # 1, 2, 3, 4 and 5. The facility did not document a treatment plan update to include an assessment of the client ' s progress in client records # 1, 2, 3, 4 and 5.
Client # 1 was admitted on 4/1/12. The treatment plan updates in client # 1 ' s record dated 5/31/12, 6/18/12, and 7/10/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 2 was admitted on 4/1/12. The treatment plan updates in client # 2 ' s record dated 5/17/12, 6/15/12, and 7/17/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 3 was admitted on 4/1/12. The treatment plan updates in client # 3 ' s record dated 4/27/12, 5/11/12, 6/11/12, and 6/27/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 4 was admitted on 4/1/12. The treatment plan updates in client # 4 ' s record dated 5/13/12, 6/13/12, and 7/17/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 5 was admitted on 4/1/12. The treatment plan updates in client # 5 ' s record dated 5/17/12 and 7/16/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
The findings were confirmed by the Director of Quality Improvement on August 7, 2012.
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Plan of Correction
Project Transition has revised its treatment plan process for its treatment plan updates to include an assessment of the member's progress towards goals. The new treatment plan process will be fully integrated in all programs by 10/15/2012. Project Transitions Quality Improvement Department will audit the member's clinical chart to verify that the treatment plan updates show an assessment of progress towards goals. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative records, the facility failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
On August 6, 2012, the facility ' s administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services. The facility did not document a financial audit for the 2010 and 2011 fiscal year.
The findings were confirmed by the Director of Quality Improvement on August 6, 2012.
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Plan of Correction
Project Transition is currently engaged with an outside accounting firm who is conducting an independent financial audit. The results of this audit will be completed by 10/1/2012. Project Transition will yearly continue to have an independent financial audit yearly. |
709.26(e)(1) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(1) The employe's right to inspect his own records.
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Observations
Based on the review of personnel records, the facility failed to demonstrate efforts toward informing staff of the right to inspect their own record.
The findings include:
On August 6, 2012, five personnel records were reviewed for notification of the right to inspect their record, specifically personnel records # 2, 3, 4, 5 and 6. The facility did not document that employees were informed of the right to inspect their own record in personnel records # 2, 3, 4, 5 & 6.
The findings were confirmed by the Director of Quality Improvement on August 6, 2012.
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Plan of Correction
Project Transition has revised its staff rights form to include the right to inspect his/her file. This form was reviewed with the onsite surveyor to verify that it meet the regulations. All staff will have an update signed staff rights in his/her personnel file by 10/1/2012. All new employees effective immediately will have the updated member rights in his/her personnel file. |