INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14, 2023, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records and a discussion with facility staff, the facility failed to provide documentation that the clinical supervisor participated in monthly meetings with their supervisor for the first six months of employment in one applicable record reviewed.
Employee # 2 was hired as the clinical supervisor on March 17, 2022 and was current in that position at the time of the inspection. Although this employee's date of promotion was prior to the previous inspection, they were not identified as a clinical supervisor during the previous inspection, thus their credentials were not reviewed. No supervision meetings were documented for the employee's first six months of employment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Transition's Clinical Supervisor did not have supervision notes. We do have a new Executive VP of Clinical and Program Operations. She will ensure that notes are taken during supervision. Project Transition has created a new KPI document that looks at supervision at least monthly and is tracked by the Project Director on a monthly basis. This will be monitored and reviewed by the Quality Team quarterly. |
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.
This is a repeat citation from the September 22, 2022 annual licensing renewal inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The former Director of Finance is no longer with the company. The financial audit for this year has been started and should be completed by 9/30/23. A new Director of Finance has been hired and will ensure that audits are completed in a timely manner. This will be monitored by the Quality team and reviewed with the Finance team on a quarterly basis to ensure completion. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, in one of two applicable personnel records reviewed.
Employee #2 was hired as the clinical supervisor on March 17, 2022 and is current in that position. There was no annual performance evaluation documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed by the Facility Director, Project Director and the VP of Human Resources. The Facility Directors will monitor and complete annual performance evaluations for all employees on an annual basis. The annual performance review was added to the new supervision and KPI document that is completed on a monthly basis. The Project Director will ensure these documents are completed on a quarterly basis. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation, during the preadmission process, in four of four applicable records reviewed.
Client # 1 was admitted on December 22, 2022 and was discharged on May 26, 2023. The psychosocial evaluation was not completed until May 10, 2023.
Client # 4 was admitted on March 23, 2023 and was discharged on May 17, 2023. The record did not contain a psychosocial evaluation.
Client # 5 was admitted on January 3, 2023 and was active at the time of the inspection. The psychosocial evaluation was not completed until May 30, 2023.
Client # 6 was admitted on December 13, 2022 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director, Facility Director and the Clinical Supervisor. Upon closer review, Project Transition's new Electronic Health Record had a glitch when we first moved into the new system. It would not save the Biopsychosocial upon completion so some of the earlier assessments are not able to be recovered. The issue has been corrected within the EHR. The Quality Team will add the Biopsychosocial to the admission audit that is completed quarterly. The Executive Clinical Director will ensure all Biopsychosocial Assessments are completed by day of admission. |
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 document treatment plan updates within the regulatory timeframe in five of six applicable records reviewed.
Client # 1 was admitted on December 22, 2022 and was discharged on May 26, 2023. A treatment plan update was completed on March 31, 2023, and the next treatment plan update was due no later than May 1, 2023; however, the next update was not completed until May 5, 2023.
Client # 2 was admitted on November 9, 2022 and was discharged on March 31, 2023. The treatment and rehabilitation plan was completed on November 10, 2022, and the treatment plan update was due no later than December 10, 2022; however, the update was not completed until March 14, 2023.
Client # 3 was admitted on May 12, 2022 and was discharged on February 24, 2023. A treatment plan update was completed on November 30, 2022 and the next treatment plan update was due to be completed by December 30, 2022; however, the update was not completed until February 6, 2023.
Client # 5 was admitted on January 3, 2023 and was active at the time of the inspection. A treatment plan update was completed on January 26, 2023 and the next treatment plan update was due to be completed by February 26, 2023; however, the update was not completed until May 3, 2023. The subsequent update was due to be completed by June 3, 2023; however, it was not completed until June 15, 2023. The following update was due to be completed by July 15, 2023; however, it was not completed until August 1, 2023.
Client # 6 was admitted on December 13, 2022 and was active at the time of the inspection. A treatment plan update was completed on February 14, 2023, and the next treatment plan update was due no later than March 14, 2023; however, the update was not completed until April 13, 2023. The subsequent treatment plan update was due to be completed by May 13, 2023; however, the update was not completed until May 30, 2023.
This is a repeat citation from the September 22, 2022 annual renewal licensing inspection.
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 Supervisor. Project Transition has re-trained the clinical team on the importance of having the Treatment Plan completed every 30 days. The Quality Department will audit on a weekly basis to ensure all Member has a current Treatment Plan. This information will be reviewed in a weekly meeting with the Facility Director, Project Director and Clinical Supervisor. |
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 ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every 60 days, per the facility ' s policy, in three of six applicable records reviewed.
Client # 1 was admitted on December 22, 2022 and was discharged on May 26, 2023. A case consultation was documented on February 16, 2023, and the next consultation was due to be completed by April 16, 2023; however, it was not completed until May 18, 2023.
Client # 3 was admitted on May 12, 2022 and was discharged on February 24, 2023. A case consultation was documented on November 10, 2022, and the next consultation was due to be completed by January 10, 2023; however, it was not completed until February 2, 2023.
Client # 6 was admitted on December 13, 2022 and was active at the time of the inspection. A case consultation was documented on February 23, 2023, and the next consultation was due to be completed by April 23, 2023; however, it was not completed until July 13, 2023.
This is a repeat citation from the September 22, 2022 annual renewal licensing inspection.
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 and Clinical Supervisor. Project Transition will add the Big Team (Case Consult) to the weekly auditing tool that is reviewed with the Project Director, Facility Director and Clinical Supervisor. The Project Director will ensure that these are completed every 60 days. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including monthly follow-up information, per the facility ' s policy and procedures, in four of four applicable records reviewed.
Client # 1 was admitted on December 22, 2022 and was discharged on May 26, 2023. The client record did not contain documentation of follow-up information.
Client # 2 was admitted on November 9, 2022 and was discharged on March 31, 2023. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on May 12, 2022 and was discharged on February 24, 2023. The client record did not contain documentation of follow-up information.
Client # 4 was admitted on March 23, 2023 and was discharged on May 17, 2023. The client record did not contain documentation of follow-up information.
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. To prevent this issue from occurring in the future, Project Transition added Discharge Follow Up to the KPIs, which will be monitored a minimum of monthly by the Facility Director. The Regional Operations Director will ensure that follow up documentation is being completed. |