INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 30, 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of two applicable personnel records reviewed.
Employee #3 was hired as a counselor on November 7, 2022 and was due to receive the HIV/AIDS training and the TB/STD training no later than November 7, 2023; however, both trainings were completed after one year, as the HIV/AIDS training was completed on January 30, 2024 and the TB/STD training was completed on January 28, 2024.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Findings were reviewed with Manager of Training and Education and Project Director. The Manager of Training and Education has identified HIV/AIDS and TB/STD trainings for all employees who have not received these trainings within the required time periods. These trainings will be completed by 12/15/24 under direct responsibility of the Manager of Training/Education. This will also be moniterd by our Human Resources Manager to audit personnel/training files to ensure compliance for current and new employees |
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 their partial hospitalization program did not exceed the minimum of one Full Time Equivalent (FTE) counselor providing direct counseling services to every ten clients.
The FTE is determined by dividing the total number of hours counselors devoted to their clients (40) by the project workweek (40) as 40 / 40 = 1. Then, to obtain the overall ratio, the total number of clients on the partial hospitalization caseload (13) is divided by the FTE (1) as 13 / 1 = 13 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on review of the facility's August 2023 through June 2024 fire drill logs, the facility failed to document, on their written fire drill log, the specific time for when the fire drill was conducted in February 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Facility Director. 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 without leaving anything blank. The Facility Director will sign off on all fire drills ensuring all documentation is correct.
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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
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 include reference to the drug and alcohol treatment activities.
There was no financial audit completed for the inspection's 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 22, 2022 and August 14, 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. |
709.28 (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.
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Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #5 was admitted into the partial hospitalization activity on April 4, 2023 and was discharged on May 12, 2024. A release of information form to the funding source was signed and dated by the client on April 4, 2023; however, the form was valid for one year and expired on April 4, 2024. An updated release of information form was not signed by the client and there was evidence of disclosures to the funding source from April 5, 2024 through the date of discharge.
This is a repeat citation from the September 27, 2022 and August 24, 2023 annual licensing renewal inspections.
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 Facility Director. Within the new Electronic Health Record, the form was re-built with the next one scheduled. This schedule consent will automatically come up on the list of due items for the staff. The Project Director will ensure all consents are fill out completely and correctly for all Members.
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709.34 (c) (2) 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:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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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 death or serious injury to due trauma, suicide, medication error or unusual circumstances of a client.
On June 11, 2024, the facility was notified of the off-site death of an active client. 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 seven client records reviewed.
Client #1 was admitted into the partial hospitalization activity on October 24, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 24, 2023 and the first update was due no later than November 24, 2023; however, the update was completed on December 7, 2023. Also the next treatment plan update was due no later than January 7, 2024; however, the update was completed on January 22, 2024. Additionally, a treatment plan update was completed on May 24, 2024 and the next update was due no later than June 24, 2024; however, the update was completed on June 28, 2024.
Client #2 was admitted into the partial hospitalization activity on November 28, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 28, 2023, and the first update was due no later than December 28, 2023; however, the update was completed on January 8, 2024. Additionally, a treatment plan update was completed on March 11, 2023, and the next update was due no later than April 11, 2024; however, the update was completed on April 15, 2024.
Client #4 was admitted into the partial hospitalization activity on November 16, 2023 and was discharged on January 14, 2024. The individual treatment and rehabilitation plan was completed on November 16, 2023, and the first update was due no later than December 16, 2023; however, the update was not completed prior to discharge.
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. Additionally 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.
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709.83(a)(10) 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:
(10) Discharge summary.
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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 a discharge summary, in two of four applicable client records reviewed.
Client #4 was admitted into the partial hospitalization activity on November 16, 2023 and was discharged on January 14, 2024. There was no documentation of a discharge summary in the record at the time of inspection.
Client #8 was admitted into the partial hospitalization activity on June 28, 2022 and was discharged on December 17, 2023. There was no documentation of a discharge summary in the record at the time of inspection.
This is a repeat citation from the August 24, 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 and the Facility Director. To prevent this issue from occurring in the future, Project Transition added APPLE - Leave (Discharge Summaries) 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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709.83(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 #4 was admitted into the partial hospitalization activity on November 16, 2023 and was discharged on January 14, 2024. There was no documentation of follow-up information in the record at the time of inspection.
Client #8 was admitted into the partial hospitalization activity on June 28, 2022 and was discharged on December 17, 2023. There was no documentation of follow-up information in the record at the time of inspection.
This is a repeat citation from the August 24, 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 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 27, 2022 and August 24, 2023 annual licensing inspections. Failing to complete an annual financial audit was again found to be a deficiency in the July 30, 2024, annual licensing inspection.
A plan of correction for failing to obtain an informed and voluntary consent from the client for the disclosure of information was submitted and approved by the Department for the September 27, 2022 and August 24, 2023 annual licensing inspections. Failing to obtain and informed and voluntary consent from the client for the disclosure of information was again found to be a deficiency in the July 30, 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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