INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 4, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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709.24 (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
The facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in 1 of 7 client records.
Client #2 was admitted on April 25, 2019 and was active at the time of inspection. The written procedure manual stated that the initial treatment plan must be developed within 24 hours from admission; however, the completed initial treatment plan for Client #2 was not completed until June 21, 2019.
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, the Facility Director and the Vice President of Clinical Services. Based on the review of these findings, the Vice President of Clinical Services will conduct a re-training on the Treatment Planning process to ensure that initial Treatment Plans are reviewed and signed upon admission. This re-training will occur 9/26/19. The Vice President of Clinical Services will ensure that Treatment Plans are timely and will use progressive discipline if trends of non-compliance are found with individual clinicians. |
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
The facility failed to provide documentation of an annual financial audit of the activities associated with the project's drug and alcohol abuse services for the project's prior fiscal year.
The findings were discussed 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 is currently conducting an independent financial audit. The results of this audit will be completed by October 2019. Project Transition will continue to have an independent financial audit yearly. Project Transition has hired a new Director of Finance and has also purchased and implemented new systems which should improve timeliness of our annual audit. The Director of Finance will ensure that the financial audit is completed within 6 months of the following year.
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of seven client records reviewed.
Patient #2 was admitted into the partial hospitalization activity on April 25, 2019 and was active at the time of inspection. There were consent to release information forms to the funding source, signed and dated by client, which allowed for the release of all progress notes, assessments, care plans, drug and alcohol history, which exceeded 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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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 will need to re-design the consent. The consent will be updated by 10/15/19 and will include disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b). The Facility Director will ensure that consents are completed for all Members. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
The facility failed to include, in their current medication control policy, a procedure where disinfectants and drugs for external use are to be stored separately from oral and injectable drugs.
The findings were discussed 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 Medication Management Policy was updated to include (ii) disinfectants and drugs for external use are stored separately from oral and injectable drugs. This policy was updated and approved on 9/6/19. All policies will be reviewed by the Quality Department to ensure that all required regulations are included. |
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
The facility failed to provide treatment plan updates within the regulatory timeframe in three of seven client records reviewed.
Client #1 was admitted on May 14, 2018 and was active at the time of inspection. A treatment plan update was completed on April 11, 2019 and the next update was due no later than May 11, 2019. However, the update was not completed until May 21, 2019.
Client #3 was admitted on November 23, 2018 and was active at the time of inspection. A treatment plan update was completed on March 22, 2019 and the next update was due no later than April 22, 2019. However, the update was not completed until June 19, 2019.
Client #4 was admitted on August 24, 2018 and was discharged May 31, 2019. A treatment plan update was completed on March 22, 2019 and the next update was due no later than April 22, 2019. However, the update was not completed until May 14, 2019.
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, the Facility Director and the Vice President of Clinical Services. Based on the review of these findings, the Vice President of Clinical Services will conduct a re-training on the Treatment Planning process to ensure that Treatment Plans are reviewed and signed every 30 days. This re-training will occur 9/26/19. The Vice President of Clinical Services will ensure that Treatment Plans are timely and will use progressive discipline if trends of non-compliance are found with individual clinicians. |