INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2013 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the staffing requirements facility summary reports, the project failed to employ a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
The findings include:
The staffing requirements facility summary reports for the project's five facilities were reviewed on September 6, 2013 as part of an administrative review. The project employed 10.3 full-time equivalent (FTE) counselors and/or counselor assistants as of September 6, 2013, which meant that it was required to employ at least one full-time clinical supervisor. However, as per the staffing requirements facility summary reports, the project failed to employ at least one full-time clinical supervisor.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings were reviewed with Senior Administration and a subsequent reorganization of duties was implemented to be effective 11/1/13. The CEO will assume Project Director Responsibilities. The VP's of Program Operations and of Quality have been re-assigned as Clinical Supervisors. A new Director of Quality/Licensing has been retained to start duties on 10/21/13.
Person Responsible: Project Director |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's staffing requirements facility summary report, the facility failed to provide documentation of six hours of HIV/AIDS and/or at least four hours of TB/STD training for four employees reviewed.
The findings include:
The facility's staffing requirements facility summary report was reviewed on September 6, 2013 as part of an administrative review. The facility failed to ensure that employees # 6, 7, 8 and 9 received a minimum of six hours of HIV/AIDS and/or at least four hours of TB/STD training within the required time frame.
Employee # 6 was hired as a clinician on May 12, 2008, and was required to obtain at least four hours of TB/STD training by May 12, 2009. Employee # 6 failed to obtain the training as of the date of the inspection.
Employee # 7 was hired as support staff on June 14, 2010, and was required to obtain six hours of HIV/AIDS and at least four hours of TB/STD training by June 14, 2012. Employee # 7 failed to obtain both trainings as of the date of the inspection.
Employee # 8 was hired as support staff on February 8, 2010, and was required to obtain six hours of HIV/AIDS and at least four hours of TB/STD training by February 8, 2012. Employee # 8 failed to obtain the both trainings as of the date of the inspection.
Employee # 9 was hired as support staff on August 6, 2010, and was required to obtain six hours of HIV/AIDS and at least four hours of TB/STD training by August 6, 2012. Employee # 9 failed to obtain the training's as of the date of the inspection.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Findings were reviewed with Manager of Training and Education and Project Director. The Manager of Training and Education has identified HIV/AIDS and TB/STD trainings for all employees who have not received these trainings within the required time periods. These trainings will be completed by 12/15/13 under direct responsibility of the Manager of Training/Education. Additionally, a Human Resources Manager has been hired as of 10/1/13 to audit personnel/training files to ensure compliance for current and new employees |
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 the review of the facility's fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.
The findings include:
The facility's fire drill record was reviewed on August 30, 2013. Twelve months of fire drills were reviewed. The facility's hours of operation are from 8:00 AM until 9:00 PM. The facility failed to document fire drills between the hours of 2:30 PM- 9:00 AM as all drills were documented before 2:30 PM.
The findings were forwarded to a project representative and were not disputed.
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Plan of Correction
Finding 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.
Person Responsible: Facility Director |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent form for the disclosure of client information and/or exceeded the restrictions imposed at 4 Pa. Code 255.5(b) in three of five client records.
The findings include:
Five client records requiring documentation of an informed and voluntary consent form for the disclosure of client information were reviewed on September 16, 2013. The facility failed to obtain an informed and voluntary consent form for the disclosure of client information and/or exceeded the restrictions imposed at 4 Pa. Code 255.5(b) in client records # 1, 4, and 5.
Client # 1 was admitted on 5/3/13 and was still an active client on 9/16/13. Client # 1 signed and dated a consent form for the disclosure of client information on 5/14/13 that was for a governmental agency. The consent form included documentation that allowed for the release of "any records needed for 'redacted government agency name' " which exceeded the restrictions imposed at 4 Pa. Code 255.5(b).
Client # 4 was admitted on 11/26/12. Client # 2 signed and dated a consent form for the release of client information on 12/19/12 for a government agency. The consent allowed for the release of "psychiatric evaluations, biopsychosocial assessment, and medical history including physical exam" which exceeded the restrictions imposed at 4 Pa. Code 255.5(b)
Client # 5 was admitted on 12/27/12. On 8/26/13 the facility contacted client # 5's case manager; however there was no consent to release client information form for a case manager in the client record.
The Quality Assurance Director confirmed the findings.
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Plan of Correction
Findings reviewed with Facility Director, Admissions Director and Program Administrative Coordinator. Effective immediately, all release forms have been revised to limit release of information to restrictions imposed in 4 PA Code 255.5(b).
Persons Responsible: Director of Admissions and Facility Director
Compliance verified through monthly audit by Program Administrative Coordinator |