INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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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
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The Facility Director confirmed that no annual financial audit was conducted for the preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Director of Finance and the CEO. Project Transition is currently engaged with an outside accounting firm who is currently conducting an independent financial audit. The results of this audit will be completed by October 2018. Project Transition will continue to have an independent financial audit yearly. The Director of Finance will ensure that the audit will be started earlier to ensure that it has been completed within 6 months of the following year. |
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
The facility failed to ensure that personnel records contained documentation of an annual written individual performance evaluation in two employee records.
Employee # 1 was hired as a Project Director on September 1, 2014. There was no documentation of an annual written individual performance evaluation completed for the review year.
Employee # 3 was hired as a Clinical Supervisor on June 23, 2017. There was no documentation of an annual written individual performance evaluation completed for the review year.
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 Human Resources and Training Manager. Based on the review of these findings, the Human Resources and Training Manager has reviewed all employee records and confirmed which employees have not had an annual performance evaluation. All employees without annual performance evaluations will have them completed by 10/15/18. To prevent this issue from occurring in the future, the Human Resources and Training Manager will ensure that the annual performance evaluations are entered into Project Transition's Relias E-Learning system. The Facility Director and employee will receive notification within 30 days of the annual performance evaluation being due. This will be monitored and tracked by the Human Resources and Training Manager. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to notify the Department within 3 business days following the unusual incidents below, which were discovered during the licensing process.
The incident dates and incident reasons are:
November 18, 2017 - ambulance presence
December 18, 2017- police presence
July 8, 2018- police presence
These findings were reviewed with project and 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, Project Transition's Incident Management Process will be updated to include the notification of Unusual Incidents regardless of where the incident occurred. Project Transition's Quality and Outcomes Manager will file a written unusual incident report with the Department within 3 business days following an unusual incident. This will be monitored and tracked by the Quality and Outcomes Manager. |