INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on February 3, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on consent forms in two of seven client records reviewed.
Client # 1 was admitted on November 12, 2019 and was still active at the time of inspection. Release of information forms to a funding source, a government agency, a housing provider, and a pharmaceutical service were signed and dated by the client on November 12, 2019; however, all of the release of information forms did not document the purpose of disclosure.
Client # 2 was admitted on November 14, 2019 and was still active at the time of inspection. Release of information forms to a funding source, a government agency ,a housing provider, and a pharmaceutical service were signed and dated by the client on November 14, 2019; however, all of the release of information forms did not document the purpose of disclosure.
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. Based on the review of these findings, Project Transition will need to re-design the consent. The consent will be updated by 3/15/21 and will include purpose of disclosure. The Director of Outcomes and Systems Development will ensure the consent is updated in the EHR. The Facility Director will ensure consents are completed for all Members. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document dated signature of client on release of information forms in one of seven client records reviewed.
Client # 5 was admitted on July 30, 2020 and was still active at the time of inspection. There was a release of information form to a funding source that was signed and dated by staff on October 9, 2020; however, the dated signature of the client was not documented.
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. Based on the review of these findings, it was determined that some of the deficiencies were created by staff when the Member was unable to sign In these cases, staff never went back and obtained the Member's signature. Any consents that have been created without the Member's signature will be de-activated and new consents will be created and signed by both the staff and Member by 2/15/21. To prevent this issue from occurring in the future, Project Transition is implementing a Quality Review at the program level, which will include monitoring consents for all Members. This will be monitored by the Facility Director. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent form was offered to the client in seven of seven client records reviewed.
Client # 1 was admitted on November 12, 2019 and was still active at the time of inspection. Release of information forms to a funding source, a government agency, a housing provider, and a pharmaceutical service were signed and dated by the client on November 12, 2019; however, all of the release of information forms did not document that a copy was offered to the client.
Client # 2 was admitted on November 14, 2019 and was still active at the time of inspection. Release of information forms to a funding source, a government agency, a housing provider, and a pharmaceutical service were signed and dated by the client on November 14, 2019; however, all of the release of information forms did not document that a copy was offered to the client.
Client # 3 was admitted on February 27, 2020 and was still active at the time of inspection. Release of information forms to a funding source, a government agency, a housing provider, and a pharmaceutical service were signed and dated by the client on February 27, 2020; however, all of the release of information forms did not document that a copy was offered to the client.
Client # 4 was admitted on May 7, 2020 and was still active at the time of inspection. Release of information forms to a funding source, a government agency, a housing provider, and a pharmaceutical service were signed and dated by the client on May 7, 2020; however, all of the release of information forms did not document that a copy was offered to the client.
Client # 5 was admitted on July 30, 2020 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on October 9, 2020; however, the release of information form did not document that a copy was offered to the client. Additionally, release of information forms to an outside individual, a laboratory, and a pharmaceutical service were signed and dated by the client on February 1, 2021; however, all of the release of information forms did not document that a copy was offered to the client.
Client # 6 was admitted on February 19, 2020 and was discharged on September 23, 2020. Release of information forms to a funding source, a government agency, a housing provider, an outside individual, and an advocacy group were signed and dated by the client on February 19, 2020; however, all of the release of information forms did not document that a copy was offered to the client.
Client # 7 was admitted on February 24, 2020 and was discharged on November 2, 2020. Release of information forms to a funding source, a government agency, a housing provider, an outside individual, a mental health provider, and a pharmaceutical service were signed and dated by the client on February 24, 2020; however, all of the release of information forms did not document that a copy was offered to the client.
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. Based on the review of these findings, Project Transition will need to re-design the consent. The consent will be updated by 3/15/21 and will include a place where the Member can check if they have been offered a copy. The Director of Outcomes and Systems Development will ensure the consent is updated in the EHR. The Facility Director will ensure consents are completed for all Members. |
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 provide treatment plan updates within the regulatory timeframe in five of seven client records reviewed.
Client # 1 was admitted on November 12, 2019 and was still active at the time of inspection. A treatment plan update was completed on February 14, 2020 and the next update was due no later than March 14, 2020; however, the update was completed on March 24, 2020. Additionally, a treatment plan update was completed on April 21, 2020, and the next update was due no later than May 21, 2020; however, the update was completed on May 29, 2020.
Client #2 was admitted on November 14, 2019 and was still active at the time of inspection. A treatment plan update was completed on March 6, 2020 and the next update was due no later than April 6, 2020; however, the update was completed on April 14, 2020. Additionally, a treatment plan update was completed on June 19, 2020 and the next update was due no later than July 19, 2020; however, the update was completed on July 28, 2020.
Client # 5 was admitted on July 30, 2020 and was still active at the time of inspection. A treatment plan update was completed on October 5, 2020 and the next update was due no later than November 5, 2020; however, the update was completed on November 18, 2020.
Client # 6 was admitted on February 19, 2020 and was discharged on September 23, 2020. A treatment plan update was completed on August 5, 2020 and the next update was due no later than September 5, 2020; however, the update was not completed prior to discharge.
Client # 7 was admitted on February 24, 2020 and was discharged on November 2, 2020. A treatment plan update was completed on April 21, 2020 and the next update was due no later than May 21, 2020; however, the update was completed on May 29, 2020.
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 Director. Based on the review of these findings, the process for when Treatment Plans are signed will be updated. During the weekly Treatment Team meeting, all signing parties will need to sign at the time of review. A report will be run prior to the meeting by the Facility Director to notify staff which plans need to be reviewed and signed. This will begin 4/1/21. This will be monitored by he VP of Clinical Services. |
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 one of two applicable client records reviewed.
Client # 6 was admitted on February 19, 2020 and was discharged on September 23, 2020. There was no documentation of a discharge summary in the client record at the time of the 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. Based on the review of these findings. To prevent this issue from occurring in the future, Project Transition is implementing a Quality Review at the program level by 3/15/21, which will include monitoring Discharge documentation for all Members. This will be monitored by the Facility Director. |
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 two applicable client records reviewed.
Client # 6 was admitted on February 19, 2020 and was discharged on September 23, 2020. There was no documentation of follow-up information in the client records as of the date of the inspection.
Client # 7 was admitted on February 24, 2020 and was discharged on November 2, 2020. There was no documentation of follow-up information in the client records as of the date of the 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 is implementing a Quality Review at the program level by 3/15/21, which will include monitoring Follow Up documentation for all Members. This will be monitored by the Facility Director. |