INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed 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 has conducted an independent financial audit. The results of this audit have been completed as of 9/27/17. Project Transition will continue to have an independent financial audit yearly. The Director of Finance will ensure that the audit will be started earlier to ensure that it has been completed within 6 months of the following year. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of five personnel records, the facility failed to ensure that two personnel records contained documentation of an employee-signed, annual written individual performance evaluation.
Employee # 2 had been employed since 7/20/15 as the Facility Director. The most recent annual employee evaluation was completed on 8/9/16.
Employee # 3 had been employed since 8/10/11 and as the clinical supervisor since 2015. The annual employee evaluation, dated 3/15/17, was not signed by the employee.
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 Human Resources and Training Manager. Based on the review of these findings, the Human Resources and Training Manager has reviewed all employee records and confirmed which employees have not had an annual performance evaluation. All employees without annual performance evaluations will have them completed by 10/15/17. To prevent this issue from occurring in the future, the Human Resources and Training Manager will ensure that the annual performance evaluations are entered into Project Transition's Relias E-Learning system. The Facility Director and employee will receive notification within 30 days of the annual performance evaluation being due. This will be monitored and tracked by the Human Resources and Training Manager.
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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 seven client records, the facility disclosed information without a client signed informed and voluntary consent to release form in two records. Additionally, consent to release information forms in four client records were missing required elements.
Client #1 was admitted on 2/13/17 and was discharged 7/24/17. The record contained results for laboratory analysis dated 4/19/17, which indicated the client's presence in treatment; however, the disclosure was made without a consent to release information form or Qualified Service Organization Agreement in place. Additionally, the record contained three consent to release information forms to other service providers, all dated 2/1/17, which were not signed or dated by a witness.
Client #2 was admitted on 12/5/16 and was discharged 5/11/17. The record contained a consent to release information form to a pharmacy, signed and dated by the witness on 12/5/16, but was not signed or dated by the client.
Client #3 was admitted on 10/10/16 and was discharged 7/19/17. The record contained consent to release information forms to a pharmacy and two other treatment providers, all signed by the client on 9/4/16, but was not signed by a witness until 10/6/16.
Client #4 was admitted on 8/25/16 and was discharged on 5/11/17. The record contained consent to release information forms, one to a probation officer and one to an attorney, dated on 10/20/16 and 11/3/16 by witnesses, respectively; however, none of them were signed by the client.
Client #6 was admitted on 2/23/17 and was an active client at the time of the inspection. The record contained results for laboratory analysis dated 4/26/17, which indicated the client's presence in treatment; however, the disclosure was made without a consent to release information form or Qualified Service Organization Agreement in place.
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, the Quality and Outcomes Manager has audited all member consents. New consents are to be completed for any consents that are expired or have any other deficiencies by 10/15/17. To prevent this issue from occurring in the future, the Quality and Outcomes Manager will conduct a re-training that covers the importance of obtaining consent as well as the proper way to fill out the consent forms has occurred with staff on 10/11/17 and 10/12/17. This will be monitored and tracked by the Project Director.
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