INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 23, 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of an individual training plan developed with input from both the employee and the supervisor for one of four personnel records reviewed.
Employee #3 was hired as a counselor on December 5, 2022. The individual training plan was completed by the counselor on December 11, 2023 and the supervisor signed the training plan on May 8, 2024. There was no documentation indicating the individual training plan was developed with input from both the employee and supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director and Facility Director. All staff development plans are to be completed and signed by both staff and supervisor within the first 30 days of employment. Effective immediately, Project Transition will use progressive discipline if any staff fail to comply with completing and signing their staff development plan. This will be documented in supervision and will be reviewed and tracked by the Facility Director and Project Director. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's August 2023 through June 2024 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month during the month of March 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director and Facility Director. Project Transition's physical location was not open during the month of March 2024 due to a plumbing issue. Project Transition has since opened the office back up and has resumed conducting monthly fire drills. In the future, if an exception is needed, the Quality Department will file an exception with the Department of Drug and Alcohol. The PT Andorra Program Director will ensure that fire drills are conducted on a monthly basis. The Regional Director will review fire drills on a monthly basis to ensure that they are occurring.
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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 the date of the fire drill on the written fire drill record for the fire drill conducted in April 2024.
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 Facility Director. Based on the review of these findings, the Facility Director was re-trained on the completion of fire drills. The operability of smoke alarm/ fire alarms is completed on a different form. Project Transition will ensure that the form is completed and attached to the fire drill. The Project Director will ensure that all fire drills are completed correctly. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's August 2023 through June 2024 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's hours of operation were posted as Monday through Sunday from 8:00AM to 9:00PM. There were eleven fire drills completed during the reviewed period and all of the drills were completed prior to 3:15PM. There were no fire drills conducted during the evening and/or weekend hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Findings were reviewed with the Facility Director. Facility Director will immediately implement a rotating time of Fire Drills to encompass hours from 8am to 9pm. This will be verified through quality program audits every six weeks. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and the policy and procedure manual, the facility failed to follow several of the project's written procedures for the management of treatment/rehabilitation services in five of seven client records reviewed.
The facility policy and procedure manual stated that case consultations will be completed 30 days after admission and 60 days thereafter. Additionally, the facility policy and procedure manual stated the discharge summary will be completed within 2 weeks of discharge. Finally, the facility policy and procedure manual stated that follow-up information will be completed monthly for one year.
Client #1 was admitted on December 19, 2023 and was active at the time of the inspection. Per the policy, the first case consultation was due no later than January 19, 2024; however, the first case consultation was completed on May 9, 2024.
Client #2 was admitted on October 19, 2023 and was active at the time of the inspection. Per the policy, the first case consultation was due no later than November 19, 2023; however, the first case consultation was completed on June 27, 2024.
Client #6 was admitted on April 10, 2024 and was discharged on May 16, 2024. Per the policy, the discharge summary was due no later than May 30, 2024; however, the discharge summary was completed on June 20, 2024.
Client #7 was admitted on May 2, 2024 and was discharged on May 30, 2024. Per the policy, the discharge summary was due no later than June 13, 2024; however, the discharge summary was completed on June 20, 2024.
Client #8 was admitted on August 9, 2022 and was discharged on February 15, 2024. Per the policy, follow-up information was due for the months of March, April, May, and June of 2024 at the time of the inspection; however, the facility completed follow-up information only during the month of March 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 Project Director and Facility Director. Based on the review of these findings, the Executive Director of Clinical Services will conduct a re-training on the Treatment Planning process to ensure each Treatment Planning (Case Consultation) session is documented. Project Transition will also retrain staff on the workflows that were implemented in the new Electronic Heatlh Record (EHR). These workflows include scheduling the Treatment Planning session within 30 days of admission and include reminders to ensure that it occurs. The Project Director will ensure that each Member is received a Treatment Planning session within the first 30 days in the program. |
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 Director 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.
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709.34 (c) (3) 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:
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
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Observations
Based on a review of the facility's August 2023 through June 2024 fire drill logs and a discussion with facility staff, the facility failed to file a written unusual incident report with the Department within 3 business days following a significant disruption of services due to a disaster such as fire, storm, flood, or other occurrence that results in the closure of the facility for more than 1 day.
The facility experienced a flood on March 8, 2024 and was closed through April 15, 2024. There was no unusual incident report regarding the facility closure filed with 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. Based on the review of these findings, Project Transition's Incident Management Process will be updated to include the notification of Unusual Incidents if the occurred. Project Transition's Quality and Outcomes Manager will file a written unusual incident report with the Department within 3 business days following an unusual incident. This will be monitored and tracked by the Quality and Outcomes Manager.
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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 five applicable client records reviewed.
Client #1 was admitted on December 19, 2023 and was active at the time of the inspection. A treatment plan update was completed on April 29, 2024, and the next update was due no later than May 29, 2024; however, the update was completed on June 4, 2024.
Client #2 was admitted on October 19, 2023 and was active at the time of the inspection. A treatment plan update was completed on December 26, 2023, and the next update was due no later than January 26, 2024; however, the update was completed on February 27, 2024. Additionally, a treatment plan update was completed on April 30, 2024 and the next update was due no later than May 30, 2024; however, the update was completed on June 4, 2024.
Client #4 was admitted on February 22, 2024 and was discharged on June 11, 2024. A treatment plan update was completed on April 24, 2024, and the next update was due no later than May 24, 2024; however, the update was completed on May 31, 2024.
This is a repeat citation from the September 22, 2022 and August 14, 2023 annual licensing renewal inspections.
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. |
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 three of four applicable client records reviewed.
Client #5 was admitted on March 19, 2024 and was discharged on April 11, 2024. There was no documentation of follow-up information in the record at the time of inspection.
Client #6 was admitted on April 14, 2024 and was discharged on May 16, 2024. There was no documentation of follow-up information in the record at the time of inspection.
Client #7 was admitted on May 2, 2024 and was discharged on May 30, 2024. There was no documentation of follow-up information in the record at the time of inspection.
This is a repeat citation from the August 14, 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. |
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 22, 2022 and August 14, 2023 annual licensing inspections. Not completing an annual financial audit was again found to be a deficiency in the July 23, 2024, annual licensing inspection.
A plan of correction for completing treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the September 22, 2022 and August 14, 2023 annual licensing inspections. Not completing treatment plan updates within the regulatory timeframe was again found to be a deficiency in the July 23, 2024, annual licensing inspection.
These findings were 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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