INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on March 22-23, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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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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 the 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 March 23, 2012, the facility's administrative records were reviewed for documentation of a certificate of occupancy. The facility did not have a certificate of occupancy.
An interview with the facility director on March 23, 2012 confirmed the findings.
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Plan of Correction
A valid Certificate of Occupancy was forwarded to Licensing Supervisors and the on-site Licensing Specialist on 3/27/12 by the Senior Director, Admissions and Administration.
Project Transition will not move prior to notifying the Division in writing and providing the Division with all required documentation to include a copy of a valid Certificate of Occupancy. |
705.21 (3) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
Based on a review of the administrative records, the facility failed to provide a zoning permit verifying that the building/area is zoned for the intended use and purpose of the facility.
The findings include:
On March 23, 2012, the facility's administrative records were reviewed for documentation of a zoning permit. The facility did not have a zoning permit.
An interview with the facility director on March 23, 2012 confirmed the findings.
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Plan of Correction
A valid Certificate of Occupancy was forwarded to Licensing Supervisors and the on-site Licensing Specialist on 3/27/12 by the Senior Director, Admissions and Administration.
A Valid zoning permit will be forwarded to the Division by 5/31/2012
Project Transition will not move prior to notifying the Division in writing and providing the Division with all required documentation to include a copy of a valid Zoning Permit. |
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 to include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan in two out of two records.
The findings include:
On March 23, 2012, two client records requiring treatment plan updates were reviewed, specifically records # 2 and 3. The facility did not document a treatment plan update to include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan in client records # 2 and 3.
Client # 2 was admitted on 2/1/12. The treatment plan update in client # 2 ' s record dated 3/6/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 3 was admitted on 2/2/12. The treatment plan update in client # 3 ' s record dated 3/10/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
An interview with the facility director on March 23, 2012 confirmed the findings.
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Plan of Correction
As of 5/1/12, all Treatment Plans will include an assessment of progress in relationship to stated goals. The Director of Quality Improvement will work with the Director of Clinical Management to ensure that this information is shared with all staff by 5/1/12. In order to prevent this deficiency from occurring again, the Senior Director, Program Administration and Quality and the Director of Quality Improvement will include this item in the audit process. |
709.82(e)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on a review of the administrative records, the facility failed to document resources for assisting their clients in obtaining legal services.
The findings include:
On March 23, 2012, the facility's letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a referral source to assist clients in obtaining legal services. Additionally, the facility could not produce a client record showing that they had assisted any client in obtaining legal services.
An interview with the facility director on March 23, 2012 confirmed the findings.
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Plan of Correction
The Director of Quality Improvement will obtain an updated letter of agreement for legal services in Berks County by 5/15/12. The Director of Quality Improvement will develop a tracking sheet by 5/15/12 for all letters of agreement to ensure that they are completed within the specified timeframe. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the administrative records, the facility failed to make available to the public an annual report.
The findings include:
On March 23, 2012, the facility's administrative records were reviewed for documentation of their annual report's availability to the public. The facility did not notify the public about their 2011 annual report.
An interview with the facility director on March 23, 2012 confirmed the findings.
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Plan of Correction
The Director of Community Relations and Marketing will post the information regarding the availability of public viewing of the annual report on the Project Transition website by 5/1/12. The Director of Community Relations and Marketing will post the information upon completion of the annual report each year moving forward. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the administrative records, the facility failed to document an annual report to include a financial statement of income and expenses.
The findings include:
On March 23, 2012, the facility's 2011 annual report was reviewed. The 2011 annual report did not include a financial statement of income and expenses.
An interview with the facility director on March 23, 2012 confirmed the findings.
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Plan of Correction
The 2011 Annual Report will be revised by the Chief Executive Officer to include a financial statement of income and expenses by 5/15/12.
The Director of Quality Improvement will review annual report prior to it being finalized to ensure that it includes a financial statement of income and expenses before it is finalized, on an annual basis. |
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 the 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 March 23, 2012, the facility's administrative records were reviewed for documentation of an annual audit of financial activities. The facility did not document a financial audit for the 2010 fiscal year.
An interview with the facility director on March 23, 2012 confirmed the findings.
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Plan of Correction
The Senior Director of Admissions and Administration and the Chief Executive Officer will work with an independent public accountant to document an annual audit of financial activities by 6/1/12. In order to prevent this deficiency from occurring again, The Chief Financial Officer will work with an independent public accountant to ensure that an annual audit of financial activities is completed. |
709.26(e) 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:
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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 in three of three personnel records.
The findings include:
On March 23, 2012, three personnel records were reviewed for notification of the right to inspect their own record, specifically records # 2, 3 and 4. The facility did not document that the employees were informed of the right to inspect their own records in personnel records # 2, 3 and 4.
An interview with the facility director on March 23, 2012 confirmed the findings.
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Plan of Correction
The Director of Quality Improvement will work with the Manager of HR and Training to revise the paperwork provided to staff to include the right to inspect his/her own record by 5/1/12. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation, the facility failed to secure all client records within locked storage containers.
The findings include:
On March 22, 2012, at approximately 10:30 AM, the licensing specialist observed client records unattended in an unlocked filing cabinet.
An interview with the facility director on March 23, 2012 confirmed the findings.
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Plan of Correction
The Program Director of the Berks Program spoke with the staff of the Berks Program on 3/23/12 to remind them of the process for maintaining confidentiality of member records, including keeping the records in a locked cabinet in a locked room. The Diretor of Quality Improvement will audit this process on a monthly basis to ensure compliance. |