INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19, 2026 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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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 client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client #4 was admitted on February 26, 2025 and was discharged on March 19, 2026. The release of information form to the funding source was signed by the client on February 26, 2025 and expired on February 26, 2026. There was evidence of disclosures to the funding source after the release form expired; however, there was no new or updated consent to release information form signed by the client documented in the record prior to any disclosures made after February 26, 2026.
This is a repeat citation from the August 21, 2025 annual licensing renewal 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 Facility Director. Within the Electronic Health Record, the form allows to schedule the next due consent for each entity. We have discovered a report to run that will show scheduled tasks for all staff and clients. The use of this scheduling function will be re-trained. The Project Director will ensure all consents are filled out completely and correctly for all Members. This training will occur on 9/2/26 during Project Transition's Multi-Department Meeting. This will be re-iterated during the Case Manager Quarterly Meeting this fall. |
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 five of six applicable client records reviewed.
Client #1 was admitted on April 24, 2026 and was still active at the time of the inspection. A treatment plan update was completed on July 14, 2026 and the next update was due no later than August 14, 2026; however, the update was completed on August 17, 2026.
Client #2 was admitted on June 11, 2026 and was still active at the time of the inspection. The individual treatment plan was completed on June 11, 2026 and the first update was due no later than July 11, 2026, however the update was completed on July 15, 2026.
Client #5 was admitted on December 4, 2024 and was discharged on March 23, 2026. A treatment plan update was completed on October 31, 2025 and the next update was due no later than November 30, 2025; however, the update was completed on December 4, 2025. Additionally, a treatment plan update was completed on February 5, 2026 and the next update was due no later than March 5, 2026; however, the update was not completed prior to discharge.
Client #6 was admitted on June 2, 2025 and was discharged on March 13, 2026. A treatment plan update was completed on November 13, 2025 and the next update was due no later than December 13, 2025; however, the update was completed on January 12, 2026. Additionally, a treatment plan update was due to be completed on February 12, 2026; however, the update was completed on March 12, 2026.
Client #7 was admitted on June 2, 2025 and was discharged on June 18, 2026. A treatment plan update was completed on November 12, 2025 and the next update was due no later than December 12, 2025; however, the update was completed on January 9, 2026. Also, the next update was due no later than February 9, 2026; however, the update was completed on March 11, 2026. The next update was due no later than April 11, 2026; however, the update was completed on May 11, 2026. Additionally, a treatment plan update was due to be completed on June 11, 2026; however, the update was not completed prior to discharge.
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/ Facility Director, Regional Director, Program Director and the VP of Clinical Excellence. Project Transition has re-trained the clinical team on the importance of having the Treatment Plan completed in a timely manner. 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 Project Director/ Facility Director, Regional Director, Program Director and VP of Clinical Excellence. A re-training was completed during the Clinical Rounds meeting on 8/27/26.The VP of Clinical Excellence will ensure Treatment Plans are completed timely. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in two of six applicable client records reviewed.
The facility's policy and procedure manual stated case consultations will occur every 60 days.
Client #1 was admitted on April 24, 2026 and was still active at the time of the inspection. A case consultation was completed on May 12, 2026 and the next case consultation was due to be completed no later than July 11, 2026; however, the consultation was completed on July 14, 2026.
Client #2 was admitted on June 11, 2026 and was still active at the time of the inspection. A case consultation was completed on June 16, 2026 and the next case consultation was due to be completed no later than August 15, 2026; however, the consultation was completed on August 18, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This was reviewed with the Project Director/ Facility Director, Regional Director, Program Director and VP of Clinical Excellence. Project Transition has incorporated the Big Team Note (case consultation) into the weekly Multi-Department Meeting, which involves senior leadership, regional leadership, program leadership as well as others involved in the program operations. We audit and review the Big Team notes audit each week during this meeting to ensure timely completion. A retraining will be completed to ensure the Big Team schedule stays on track and the notes are completed in a timely manner. A re-training was completed during the Clinical Rounds meeting on 8/27/26. This will be re-iterated during the Program Director Quarterly Meeting this fall. The Regional Operations Director will ensure this corrective action is implemented. |