INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16, 2014 by staff from the Division of Drug and Alcohol 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.
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Plan of Correction
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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 project's administrative documentation, the project failed to complete an annual report to include a financial statement of income and expenses for the fiscal year 2013.
The findings included:
The administrative documentation was reviewed on July 10, 2014. The annual report is to include a financial statement of income and expenses. The project failed to include the financial statement of income and expenses in the 2013 annual report.
An interview with the Director of Program Development, Quality, and Compliance on July 10, 2014 confirmed the findings.
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Plan of Correction
The findings were reviewed by the Director of Program Development, Quality and Compliance, Vice President of Quality and Program Fidelity, and the Chief Financial Officer. The financial statement of income and expenses was added to the Annual Report for fiscal year 2013 by the Chief Financial Officer.
Plan to ensure deficiency does not recur:
1. The Vice President of Quality and Program Fidelity will produce and sign off on the Annual Report and ensure that the financial statement including income and expenses is included
2. The Chief Financial Officer will review the Annual Report for accuracy before it is released.
3. The Director of Program Development, Quality and Compliance will do a final review of the Annual Report to ensure that all elements (including the financial statement) are included in the Annual Report.
Responsible Party: Chief Financial Officer, Director of Program Development, Quality and Compliance, Vice President of Quality and Program Fidelity.
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical/psych coverage.
The findings include:
The letters of agreement were reviewed on July 16, 2014. The facility documented a letter of agreement signed in February 2013. The letter of agreement failed to have documented whether the hospital had 24 hour emergency medical/psych coverage.
An interview with facility and corporate staff on July 16, 2014 confirmed the findings.
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Plan of Correction
The findings were reviewed by the Facility Director and the Director of Program Development, Quality and Compliance. A new standard letter of agreement form was drafted to include specific language stating that the facility provides 24 hour emergency medical/psych coverage. The Director of Program Development, Quality, and Compliance identified key individuals at each hospital/facility to sign the new letters of agreement. The letters were sent out for signature to each facility on 8/31/14. The signed letters of agreement will be in place by 10/01/14.
Plan to ensure deficiency does not recur:
1. The Director of Program Development Quality and Compliance has created a standard form for the letters of agreement that will be used without exception moving forward.
2. The Director of Program Development, Quality and Compliance will maintain a paper and electronic copy of all letters of agreement.
3. The Director of Program Development, Quality and Compliance will maintain a spreadsheet to track expiration dates of letters of agreement.
4. The Director of Program Development, Quality and Compliance will track and update letters of agreement when needed (every two years).
Responsible Party: Director of Program Development, Quality and Compliance.
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