INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 7, 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 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:
|
Plan of Correction
|
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.
|
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.
|
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.
|
Observations
Based on a review of five personnel records, the facility failed to ensure that there was 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 last 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 last review year.
These findings were reviewed with facility staff during the licensing process.
|
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. |
709.28 (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.
|
Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in three of five client records reviewed. Additionally, the facility failed to document a dated witness signature in one of five client records reviewed.
Client #1 was admitted to the partial level of care on August 6, 2018 and were still active. Two consent to release information forms were signed and dated on July 30, 2018 to two healthcare centers; however, both forms failed to include the dated witness signatures.
Client #2 was admitted to the partial level of care on July 3, 2017 and were still active. There was documentation of the facility billing the funding source; however, there was no consent to release information form on file prior to the disclosure of information. Additionally, there was documentation of correspondence between the facility and a family member on August 8, 2018; however, there was no consent to release information form on file prior to the disclosure.
Client #4 was admitted to the partial level of care on June 4, 2014 and was discharged on August 16, 2018. There was documentation of the facility billing the funding source; however, there was no consent to release information form on file prior to the disclosure of information.
Client #5 was admitted to the partial level of care on August 18, 2017 and was discharged on April 11, 2018. There was documentation of the facility billing the funding source; however, there was no consent to release information form on file prior to the disclosure of information.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
These findings were reviewed with the Project Director and the Facility Director. Based on the review of these findings, it was determined that some of the deficiencies were duplicate consents entered. Some of these duplicates did not have signatures on them. Any duplicate consents without signatures will be closed out and new consents are to be completed by 10/15/18. To prevent this issue from occurring in the future, Project Transition is implementing a new EHR system. Within this system, consents will be tracked and updated when necessary. This will be monitored and tracked by the Project Director. |
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.
|
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 reasons are:
April 10, 2018 - ambulance presence onsite
May 22, 2018- police presence onsite
These findings were reviewed with project and facility staff during the licensing process.
|
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. |
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.
|
Observations
The facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice a week, in two of five records reviewed in the partial hospitalization activity.
Client # 1 was admitted on August 6, 2018 and was still active at the time of the inspection. Documentation of two individual sessions per week was not completed for the week of August 12, 2018 to August 18, 2018.
Client # 4 was admitted on June 4, 2014 and was discharged on August 16, 2018. Documentation of two individual sessions per week were not completed for the following weeks:
July 8, 2018 to July 14, 2018
July 15, 2018 to July 21, 2018
July 22, 2018 to July 28, 2018
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
These findings were reviewed with the Project Director, the Facility Director and the Clinical Director. Based on the review of these findings, Project Transition will have to change its Level of Care requirements for our Level 3 members to ensure provision of at least two individual counseling sessions per week. The Project Director will ensure that all recovery track members are offered two individual sessions per week. |
709.83(a) 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:
|
Observations
The facility failed to provide a complete client record in two of five client records.
Client #4 was admitted to the partial level of care on June 4, 2014 and was discharged on August 16, 2018. The record did not contain a discharge summary or an aftercare plan.
Client #5 was admitted to the partial level of care on August 18, 2017 and was discharged on April 11, 2018. The record did not contain a discharge summary or follow-up information.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
These findings were reviewed with the Project Director and the Facility Director. Based on the review of these findings, staff will be retrained on Project Transition's Graduation/Discharge Protocols, which include an Aftercare Plan and Discharge Plan upon Graduation or Discharge from the program. This training will occur on 10/18/18. The Project Director will ensure that all Graduation/Discharge processes and protocols are occurring. |