INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13-14, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Project Transition 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of personnel records, the facility failed to document feedback on completed training.
The findings include:
On August 13, 2012 one personnel record requiring documentation of feedback on completed training was reviewed, specifically record # 1. Personnel record # 1 did not contain documentation of feedback on completed training.
Personnel # 1 completed 16.5 clock hours of training during the 2011-2012 training year, but the personnel record did not include documentation of feedback on trainings completed during the 2011-2012 training year.
The findings were confirmed by the Director of Quality Improvement on August 13, 2012.
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Plan of Correction
Being immediately Project Transition staff will be required to submit training feedback forms on all trainings they attend. This will be monitored and tracked by the Project Director |
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 the review of personnel records, the facility failed to document an individual training plan for each employee by the start of the training year.
The findings include:
Eight personnel records requiring an individual training plan were reviewed on August 13, 2012, specifically personnel records # 1, 2, 3, 4, 5, 6, 7 and 8. The facility did not document an individual training plan for the 2011-2012 training year in personnel records # 2, 3, 5, 6, 7 and 8.
Personnel # 2 was hired on 2/23/11. A training plan for the 2011-2012 training year was due to be completed in August 2011. There was no documentation of an individual training plan for 2011-2012 for this employee.
Personnel # 3 was hired on 5/4/09. A training plan for the 2011-2012 training year was due to be completed in August 2011. The individual training plan documented in the personnel record was dated " Dec. 2011 " .
Personnel # 5 was hired on 9/23/08. A training plan for the 2011-2012 training year was due to be completed in August 2011, but the training plan in personnel # 5 ' s record was dated 10/12/11.
Personnel # 6 was hired on 6/1/09. A training plan for the 2011-2012 training year was due to be completed in August 2011. The individual training plan documented in the record was dated 9/30/11.
Personnel # 7 was hired on 7/11/11. A training plan for the 2011-2012 training year was due to be completed in August 2011. The individual training plan documented in the record was dated 9/30/11.
Personnel # 8 was hired on 6/22/08. A training plan for the 2011-2012 training year was due to be completed in August 2011. There was no documentation of an individual training plan for 2011-2012 for this employee.
The findings were confirmed by the Director of Quality Improvement on August 13, 2012.
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Plan of Correction
Starting immediately staff will fill out a staff development plan with in the first 30 days of employment; this will be monitored and tracked by the HR department. Current Employees will submit staff development plans in a timely manner; this will be tracked by the HR department. Staff members that did not have staff development plans will have them completed by 9/15/2012 |
704.12(a)(5) LICENSURE Partial Hosp Ratio
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(5) Partial hospitalization. Partial hospitalization programs shall have a minimum of one FTE counselor who provides direct counseling services to every ten clients.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report form completed by the facility on August 13, 2012, the facility failed to ensure that there was one Full-Time Equivalent (FTE) Counselor for every ten clients.
The findings include:
On August 13, 2012, the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed one part-time clinical supervisor and three counselors. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the counselors devoted to the clients, 32, the total number of hours in the facility's standard work week, 40, and the total number of clients on August 13, 2012, 11, the facility failed to ensure that there was one FTE Counselor for every ten clients.
The actual FTE/client ratio is determined by dividing the FTE into the number of clients. The FTE is determined by dividing the number of hours devoted to the clients 'treatment' by the facility's standard workweek.
The number of hours per week devoted by the clinical treatment team to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 32 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that the facility had 11 active drug and alcohol clients on August 13, 2012.
Treatment team (32/40 = 0.8 FTE 11 clients/0.8 FTE = 14:1 Ratio)
The Staffing Requirements Facility Summary Report indicated the client to counselor ratio was 14 clients for each FTE counselor.
The facility director signed the Staffing Requirements Facility Summary Report on August 13, 2012 to attest to the accuracy, veracity, and authenticity of the stated information.
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Plan of Correction
Beginning immediately, Project Transition's Andorra program will maintain the appropriate Staff to member ratio. The Director of Quality Improvement will review the staff to member ratio on a monthly basis to verify that he ratio does not exceed 10:1 |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, sanitary and in good repair at all times.
The findings include:
An inspection of the facility ' s physical plant was conducted on August 14, 2012 between 12:00 PM and 12:15 PM. At the time of inspection, the grounds of the facility were not in good repair. Carpeting throughout the facility was dirty and noticeably stained.
The findings were confirmed by the Director of Quality Improvement on August 14, 2012.
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Plan of Correction
Project Transitions Facility Director had the Andorra program's carpets shampooed; this will be repeated at least every 6 months or sooner if needed. The Director of Quality Improvement will inspect the facility on a monthly basis for to verify that the grounds of the facility are clean, sanitary and in good repair at all times.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment.
The findings include:
Seven personnel records requiring documentation of fire extinguisher training were reviewed on August 13, 2012, specifically client records # 2, 3, 4, 5, 6, 7 and 8. The facility did not document that fire extinguisher training was provided upon employment in personnel records # 4 and 7.
Employee # 4 was hired for his current position on 3/26/12, but verification of fire extinguisher training was not documented at the time of review on 8/13/12.
Employee # 7 was hired for his current position on 7/11/11, but verification of fire extinguisher training was not documented at the time of review on 8/13/12.
The findings were confirmed by the Director of Quality Improvement on August 13, 2012.
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Plan of Correction
Beginning immediately staff will receive fire extinguisher training with in the first week of employment. This will be documented on a check list in staff personnel files. The Director of Quality Improvement will audit the personnel files to verify that the training is taking place |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to ensure that all personnel are trained to perform assigned task during emergencies.
The findings include:
Seven personnel records were reviewed on August 13, 2012. The facility did not document that emergency training was provided to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Six out of the seven records reviewed did not contain documentation that the employee had been trained to perform assigned tasks during emergencies, specifically personnel records # 3, 4, 5, 6, 7 and 8.
Employee # 3 was hired for his current position on 1/1/12, but verification of emergency training was not documented at the time of review on 8/13/12.
Employee # 4 was hired for his current position on 3/26/12, but verification of emergency training was not documented at the time of review on 8/13/12.
Employee # 5 was hired for his current position on 9/23/08, but verification of emergency training was not documented at the time of review on 8/13/12.
Employee # 6 was hired for his current position on 6/1/09, but verification of emergency training was not documented at the time of review on 8/13/12.
Employee # 7 was hired for his current position on 7/11/11, but verification of emergency training was not documented at the time of review on 8/13/12.
Employee # 8 was hired for his current position on 6/22/08, but verification of emergency training was not documented at the time of review on 8/13/12.
The findings were confirmed by the Director of Quality Improvement on August 13, 2012.
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Plan of Correction
Beginning immediately staff will receive site specific emergency training with in the first week of employment. This will be documented on a check list in staff personnel files. The Director of Quality Improvement will audit the personnel files to verify that the training is taking place.
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709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to document medical histories.
The findings include:
Four client records requiring medical histories were reviewed on August 14, 2012, specifically records # 1, 2, 3 and 4. The facility did not document a medical history within 30 days, as per facility policy, in records # 1, 2, 3 and 4.
Clients # 1, 2, 3 and 4 were all admitted to the facility ' s Addiction Recovery Track on 1/1/12, but client records # 1, 2, 3 and 4 did not contain an updated medical history at the time of review on 8/14/12.
The findings were confirmed by the Director of Quality Improvement on August 14, 2012.
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Plan of Correction
Starting immediately Members whom are admitted to or transfer into Project Transitions Drug and Alcohol program will have a medical history completed within 30 days of the admission or transfer beginning immediately. The Quality Department of Project Transition will Audit members clinical charts to verify that medical history is being completed within the time frame. The Director of Quality Improvement will also conduct a full training on the documentation required when a member is admitted to or transferred into Project Transitions Drug and Alcohol program. |
709.81(b)(3)(iii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records, the facility failed to document personal histories.
The findings include:
Four client records requiring personal histories were reviewed on August 14, 2012, specifically records # 1, 2, 3 and 4. The facility did not document a personal history within 30 days, as per facility policy in records # 1, 2, 3 and 4.
Clients # 1, 2, 3 and 4 were all admitted to the facility ' s Addiction Recovery Track on 1/1/12, but client records # 1, 2, 3 and 4 did not contain an updated personal history at the time of review on 8/14/12.
The findings were confirmed by the Director of Quality Improvement on August 14, 2012.
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Plan of Correction
Starting Immediately Members whom are admitted to or transfer into Project Transitions Drug and Alcohol program will have a personal history completed within 30 days of the admission or transfer beginning immediately. The Quality Department of Project Transition will Audit members clinical charts to verify that the personal history is being completed within the time frame. The Director of Quality Improvement will also conduct a full training on the documentation required when a member is admitted to or transferred into Project Transitions Drug and Alcohol program. |
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 the review of client records, the facility failed to document treatment plan updates that included an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan.
The findings include:
Four client records requiring treatment plan updates were reviewed on August 14, 2012, specifically records # 1, 2, 3 and 4. The facility did not document a treatment plan update to include an assessment of the client ' s progress in records # 1, 2, 3 and 4.
Client # 1 was admitted on 1/1/12. The treatment plan update dated 7/21/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 2 was admitted on 1/1/12. The treatment plan update dated 7/12/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 3 was admitted on 1/1/12. The treatment plan update dated 7/26/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 4 was admitted on 1/1/12. The treatment plan updates dated 7/1/12 and 8/1/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
The findings were confirmed by the Director of Quality Improvement on August 14, 2012.
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Plan of Correction
Project Transition has revised its treatment plan process for its treatment plan updates to include an assessment of the member's progress towards goals. The new treatment plan process will be fully integrated in all programs by 10/15/2012. Project Transitions Quality Improvement Department will audit the member's clinical chart to verify that the treatment plan updates show an assessment of progress towards goals. |
709.83(a)(9) 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:
(9) Progress notes.
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Observations
Based on the review of client records, the facility failed to document group progress notes that included information presented by the client during the counseling session, counselor observations and information about the client from other sources (data).
The findings include:
Four client records requiring group progress notes were reviewed on August 14, 2012, specifically, client records # 1, 2, 3 and 4. The facility did not document group progress notes to include " data " in client records # 1, 2, 3 and 4. The " Recovery Group " progress notes in client records # 1, 2, 3 and 4 only stated the topic of the group counseling session but did not provide " data " .
The findings were confirmed by the Director of Quality Improvement on August 14, 2012.
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Plan of Correction
The Drug and Alcohol's counselor was retrained on how to properly write a group DAP note. Her notes will review her group notes will be reviewed on a weekly basis to verify that she is using the DAP format correctly by the Director of Recovery Services. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the administrative records, the facility failed to make available to the public an annual report.
The findings include:
On August 13, 2012, the facility ' s administrative records were reviewed for documentation of their annual report ' s availability to the public. The facility did notify the public about their 2011 annual report.
The findings were confirmed by the Director of Quality Improvement on August 13, 2012.
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Plan of Correction
Project Transition will via its web site let the public know that its annual report is available for viewing. The web site will be updated by 10/15/2012 |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative records, the facility failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
On August 13, 2012, the facility ' s administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services. The facility did not document a financial audit for the 2010 and 2011 fiscal years.
The findings were confirmed by the Director of Quality Improvement on August 13, 2012.
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Plan of Correction
Project Transition is currently engaged with an outside accounting firm who is conducting an independent financial audit. The results of this audit will be completed by 10/1/2012. Project Transition will yearly continue to have an independent financial audit yearly.
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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on the review of personnel records, the facility failed to document the results of reference investigations.
The findings include:
Eight personnel records requiring documentation of an Employment Eligibility Verification Form (I-9 Form) were reviewed on August 13, 2012, specifically records # 1, 2, 3, 4, 5, 6, 7 and 8. The facility did not document an I-9 Form in personnel records # 1, 2, 3, 4, 5, 6, 7 and 8.
The findings were confirmed by the Director of Quality Improvement on August 13, 2012.
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Plan of Correction
Project Transition's HR Department is currently in the process or placing staff's I9 forms into their personnel files. This will be completed by 10/1/2012. Ongoing any new employee will have an I9 form placed in his/her personnel file either before or on the first day of employment. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on the review of personnel records, the facility failed to document performance evaluations.
The findings include:
Three personnel records requiring documentation of a performance evaluation were reviewed on August 13, 2012, specifically records # 1, 3 and 5. The facility did not document a performance evaluation at the completion of the first six months of employment and annually thereafter in personnel records # 1, 3 and 5.
Personnel # 1 was hired for his current position on 8/1/87. There was no documentation of a performance evaluation at the time of review on 8/13/12.
Personnel # 3 was hired for his current position on 1/1/12. There was no documentation of a performance evaluation at the time of review on 8/13/12.
Personnel # 5 was hired for his current position on 9/23/08. The last documented performance evaluation was dated 10/19/09.
The findings were confirmed by the Director of Quality Improvement on August 13, 2012.
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Plan of Correction
The current year's performance evaluations for staff #1, #3, & #5 were completed. Ongoing staff will receive a performance evaluation with in the first 6 months of employment and yearly after that. This will be monitored and tracked by the HR department. |
709.26(e)(1) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(1) The employe's right to inspect his own records.
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Observations
Based on the review of personnel records, the facility failed to demonstrate efforts toward informing staff of the right to inspect their own record.
The findings include:
On August 13, 2012, seven personnel records were reviewed for notification of the right to inspect their record, specifically records # 2, 3, 4, 5, 6 and 7. The facility did not document that employees # 2, 3, 4, 5, 6 and 7 were informed of the right to inspect their own record.
The findings were confirmed by the Director of Quality Improvement on August 13, 2012.
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Plan of Correction
Project Transition has revised its staff rights form to include the right to inspect his/her file. This form was reviewed with the onsite surveyor to verify that it meet the regulations. All staff will have an update signed staff rights in his/her personnel file by 10/1/2012. All new employees effective immediately will have the updated member rights in his/her personnel file. |