INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 22, 2022, 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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704.12(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 the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 10:1.
The overall facility Full Time Equivalent (FTE) is determined by dividing the total number of hours the facility devotes to their drug and alcohol clients by the facility's work week. Then, in order to obtain the facility's ratio, the total number of drug and alcohol clients is divided by the FTE.
The overall facility client to counselor ratio calculation is as follows:
20/40 = 0.5(FTE); 7/0.5 = 14, which equals to a client/counselor ratio of 14:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Transition has had a clinician leave and have been unable to hire another clinician. Effective immediately, we will not take on anymore Drug and Alcohol clients until we can effectively meet the requirement of a 10:1 ratio. We will continue our hiring process and increase our clients upon hire and training of another clinician. The Executive Director of Clinical will ensure our ratio stays 10:1 at a maximum. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on September 22, 2022, the facility failed to ensure that heaters were permanently mounted as space heaters were found in the Facility Director ' s office and in the second office on the left upon entering the facility.
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. All heaters were removed from the building on 9/22/22. Based on the review of these findings, confirmation that there are no space heaters in the facility was added to the Monthly Office Checklist completed by the Facility Director. The Project Director will ensure that the Monthly Office Checklist is completed at each facility and that there are no space heaters in use or in storage at the facility. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs from October 2021 through July 2022, the facility failed to ensure that a fire alarm or smoke detector was set off during each drill as the drill for June 2022 did not indicate that a smoke detector or fire alarm was set off.
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. The operability of smoke alarm/ fire alarms are 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. |
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 discussion with the facility staff, the facility failed to follow their written procedures for the management of treatment and rehabilitation services, pertaining to case consultations occurring within 30 days of admission in three of six appliable records reviewed.
Client #3 was admitted to the Partial level of care on March 3, 2022 and was discharged on August 25, 2022. There was no documentation of a case consultation by April 3, 2022.
Client #4 was admitted to the Partial level of care on March 8, 2022 and was discharged on September 16, 2022. There was no documentation of a case consultation by April 8, 2022.
Client #7 was admitted to the Partial level of care on May 12, 2022 and was active at the time of the inspection. There was no documentation of a case consultation by June 12, 2022.
These findings were reviewed with the project 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. This re-training will occur prior to 10/31/22. Project Transition will also create workflows in the new Electronic Health Record (EHR) that is being implemented on 12/1/22. These workflows will include scheduling the Treatment Planning session within 30 days of admission and will 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 a review of administrative documents submitted, 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.
The project's last annual financial audit was for the years ending December 31, 2020 and 2019.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Director of Finance. Project Transition will ask their public accountant to complete the yearly financial audit of activities earlier in the year. The Director of Finance will communicate with the public accountant to ensure this is is possible. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to assure that a copy of a client consent was offered to the client and a copy maintained in the client record in two of seven client records reviewed.
Client #4 was admitted to the Partial level of care on March 8, 2022 and was discharged on September 16, 2022. The record contained a consent to release information form to the funding source signed and dated by the client on March 8, 2022 that did not indicate a copy was offered to the client.
Client #6 was admitted to the Partial level of care on March 8, 2022 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed and dated by the client on March 8, 2022 that did not indicate a copy was offered to the client.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 14, 2021 annual licensing inspection.
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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 in 9/2021, Project Transition updated the consent form to include asking the Member if they have been offered a copy. Staff did not complete the form correctly and indicate by checking the box that the Member was offered the copy. Staff was re-trained on how to fill out a consent, ensuring that they not only offer the Member a copy but that they document it by checking off the proper box on the consent. The Project Director will ensure all consents are fill out completely and correctly for all Members. |
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 seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in five records reviewed.
Client #2 was admitted on November 10, 2020 and was discharged on May 18, 2022. A treatment plan update was completed on April 7, 2022 and another treatment plan update was due to be completed by May 7, 2022; however, the next treatment plan update was not completed until May 18, 2022.
Client #4 was admitted on March 8, 2022 and was discharged on September 16, 2022. A treatment plan update was completed on April 26, 2022 and another treatment plan update was due to be completed by May 26, 2022; however, the next treatment plan update was not completed until June 9, 2022.
Client #5 was admitted on November 3, 2021 and was active at the time of the inspection. A treatment plan update was completed on February 22, 2022 and a treatment plan update was due to be completed by March 22, 2022; however, the next treatment plan update was not completed until March 31, 2022. A treatment plan update was completed on May 2, 2022 and a treatment plan update was due to be completed by June 2, 2022, however, the next treatment plan update was not completed until June 23, 2022. A treatment plan update was completed on August 2, 2022 and a treatment plan update was due to be completed by September 2, 2022, however, the next treatment plan update was not completed until September 21, 2022.
Client #6 was admitted on March 8, 2022 and was active at the time of the inspection. A treatment plan update was completed on August 2, 2022 and a treatment plan update was due to be completed by September 2, 2022, however, the next treatment plan update was not completed until September 20, 2022.
Client #7 was admitted on May 12, 2022 and was active at the time of the inspection. A treatment plan update was completed on August 2, 2022 and a treatment plan update was due to be completed by September 2, 2022, however, the next treatment plan update was not completed until September 21, 2022.
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 Director. Based on the review of these findings, Project Transition will implement a new Electronic Health Record (EHR) that includes reminder of when Treatment Plans are due on 12/1/22. The system will have reportability to ensure Treatment Plans are completed at least every 30 days. The Clinical Director will ensure that each Member has a Treatment Plan completed at least every 30 days. Until the new system is up and running, the Executive Director of Clinical will review and ensure that Treatment Plans are completed every 30 days. This review will occur during supervision with the clinicians and during Case Consultation. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of seven records, the facility failed to ensure that counseling was provided to clients on a regular and scheduled basis, that included individual counseling, at least twice weekly in five records reviewed.
Client #2 was admitted on November 10, 2020 and was discharged on May 18, 2022. The record of service and progress notes indicated that the client did not receive an individual session for the week of March 21, 2022, and only one session each of the following weeks: March 14, 2022, March 28, 2022, April 4, 2022, April 11, 2022, and April 18, 2022.
Client #3 was admitted on March 3, 2022 and was discharged on August 25, 2022. The record of service and progress notes indicated that the client did not receive an individual session for the week of July 25, 2022, and only one session each of the following weeks: June 13, 2022, July 4, 2022, and July 18, 2022.
Client #4 was admitted on March 8, 2022 and was discharged on September 16, 2022. The record of service and progress notes indicated that the client did not receive an individual session for the weeks of July 18, 2022 and August 29, 2022 and only one session each of the following weeks: July 11, 2022, August 1, 2022, August 8, 2022, August 15, 2022 and August 22, 2022.
Client #5 was admitted on November 3, 2021 and was active at the time of the inspection. The record of service and progress notes indicated that the client did not receive an individual session for the weeks of July 18, 2022, August 8, 2022, and August 22, 2022 and only one session each of the following weeks: August 1, 2022 and August 11, 2022.
Client #7 was admitted on May 12, 2021 and was active at the time of the inspection. The record of service and progress notes indicated that the client only received one session each of the following weeks: June 20, 2022, June 28, 2022, August 15, 2022, August 22, 2022, and August 29, 2022.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
These findings were reviewed with the Project Director, the Facility Director and the Clinical Director. Project Transition will re-train the clinical team on the importance of having both sessions every week by 10/31/22. The Quality Department will audit on a monthly basis to ensure all sessions are being documented. The Executive Clinical Director will ensure all sessions are documented properly. |
709.84(e) LICENSURE Project management services
709.84. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of facility policy and procedures, the facility failed to have a follow-up policy indicating when and how clients would be followed up with.
The 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 Director. Based on the review of these findings, Project Transition will update their Discharge Follow-Up Policy to include how often and how Members will be followed up with. The Director of Outcomes and Systems Development will ensure this policy is updated, reviewed and implemented by 11/30/22. |