INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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 facility failed to provide documentation of an annual financial audit of the activities associated with the project's drug and alcohol abuse services for the project's prior fiscal year.
The findings were discussed 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 2019. Project Transition will continue to have an independent financial audit yearly. Project Transition has hired a new Director of Finance and has also purchased and implemented new systems which should improve timeliness of our annual audit. The Director of Finance will ensure that the financial audit is completed within 6 months of the following year.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in four of seven client records reviewed.
Patient #1 was admitted into the partial hospitalization activity February 6, 2018 and was active at the time of inspection. Consent to release information forms to the funding source, signed and dated by client, allowed for the release of all progress notes, assessments, care plans, drug and alcohol history which exceeded 255.5.
Patient #2 was admitted into the partial hospitalization activity on October 2, 2018 and was active at the time of inspection. Consent to release information forms to the funding source, signed and dated by client, allowed for the release of all progress notes, assessments, care plans, drug and alcohol history which exceeded 255.5.
Patient #3 was admitted into the partial hospitalization activity on November 29, 2018 and was active at the time of inspection. Consent to release information forms to the funding source, signed and dated by client, allowed for the release of all progress notes, assessments, care plans, drug and alcohol history which exceeded 255.5.
Patient #7 was admitted into the partial hospitalization activity on August 8, 2018 and was discharged November 21, 2018. Consent to release information forms to the funding source, signed and dated by client, allowed for the release of all progress notes, assessments, care plans, drug and alcohol history which exceeded 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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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 10/15/19 and will include disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b). The Facility Director will ensure that 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
The facility failed to provide treatment plan updates within the regulatory timeframe in four of seven client records reviewed.
Client # 1 was admitted on February 6, 2018 and was active at the time of inspection. A treatment plan update was completed on April 3, 2019 and the next update was due no later than May 3, 2019. However, the update was not completed until May 26, 2019.
Client # 2 was admitted on October 2, 2018 and was active at the time of inspection. A treatment plan update was completed on March 28, 2019 and the next update was due no later than April 28, 2019. However, the update was not completed until June 19, 2019.
Client # 3 was admitted on November 29, 2018 and was active at the time of inspection. A treatment plan update was completed on February 18, 2019 and the next update was due no later than March 18, 2019. However, the update was not completed until April 9, 2019.
Client # 7 was admitted on August 8, 2018 and was discharged November 21, 2018. A treatment plan update was completed on October 8, 2018 and the next update was due no later than November 8, 2018. However, the update was not completed at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director, the Facility Director and the Vice President of Clinical Services. Based on the review of these findings, the Vice President of Clinical Services will conduct a re-training on the Treatment Planning process to ensure that Treatment Plans are reviewed and signed every 30 days. This re-training will occur 9/26/19. The Vice President of Clinical Services will ensure that Treatment Plans are timely and will use progressive discipline if trends of non-compliance are found with individual clinicians. |