INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5, 2026 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 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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705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure frozen food was kept at or below 0 degrees Fahrenheit.
At the time of the inspection, conducted on August 5, 2026 at approximately 10:30am, the thermometer, located inside the freezer, had a reading of 21 degrees Fahrenheit.
This finding was 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 the Regional Operations Director. The freezer temperature was adjusted to ensure it was 0 degrees. The Freezer Logs were re-rolled out and re-trained during the Multi-Department Meeting on 9/2/26. The Freezer Log prompts staff to log the temperature and use corrective action if the reading is above 0 degrees F. Corrective action could include adjusting the freezer temperature, repairing the freezer or replacing the freezer). The Regional Operations Director will ensure that corrective action is completed if the freezer reading is above 0 degrees F. Supervision and if needed, Progressive Discipline will be used if the process is not followed. |
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, the facility failed to ensure all facility heaters were permanently mounted or installed.
At the time of the inspection, which was conducted on August 5, 2026 at approximately 10:30am, there was a portable space heater located in room #4, which was the case manager's office.
This finding was 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 8/5/26. Based on the review of these findings, a re-training of the Monthly Office Checklist will be completed. This checklist prompts staff to ensure that there are no space heaters in the facility. The Regional Operations Director will ensure that the Office Checklist is completed monthly 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 the facility's September 2025 through May 2026 fire drill logs, the facility failed to ensure a fire alarm or smoke detector was set off during each fire drill.
At the time of the inspection, there was no documentation indicating a fire alarm or smoke detector was set off during every fire drill conducted during the month of September 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director/ Facility Director, Regional Director and Program Director. Project Transition had previously decided to put in an exception request due to the upstairs neighbors being a dialysis center, however, the upstairs was converted into a laundry facility. Staff will be re-trained set off the fire alarm during fire drills. This training will be facilitated by the VP of Outcomes and Systems Development on 9/2/26 during Project Transition's Multi-Department Meeting. This will be re-iterated during the Lead RA Quarterly Meeting this fall. The Regional Operations Director will ensure the corrective action is implemented. |
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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client #6 was admitted on March 27, 2025 and discharged on March 3, 2026. The release of information form to the funding source was signed by the client on August 6, 2025 and expired on August 6, 2025. There was evidence of disclosures to the funding source after the release form expired; however, there was no new or updated consent to release information form signed by the client documented in the record prior to any disclosures made after August 6, 2025.
This is a repeat citation from the September 27, 2022, August 24, 2023, July 30, 2024, and August 27, 2025 annual licensing renewal inspections.
This finding was 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. Within the Electronic Health Record, the form allows to schedule the next due consent for each entity. We have discovered a report to run that will show scheduled tasks for all staff and clients. The use of this scheduling function will be re-trained. The Project Director will ensure all consents are filled out completely and correctly for all Members. This training will occur on 9/2/26 during Project Transition's Multi-Department Meeting. This will be re-iterated during the Case Manager Quarterly Meeting this fall. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every thirty days in six of seven client records reviewed.
Client #1 was admitted into the partial hospitalization activity on April 15, 2026 and was still active at the time of the inspection. A treatment plan update was completed on June 17, 2026 and the next update was due no later than July 17, 2026; however, the update was completed on July 20, 2026.
Client #2 was admitted into the partial hospitalization activity on December 23, 2025 and was still active at the time of the inspection. The individual treatment plan was completed on January 26, 2026 and the next update was due no later than February 26, 2026; however, the update was completed on April 8, 2026. Additionally, a treatment plan update was completed on June 11, 2026 and the next update was due no later than July 11, 2026; however, the update was completed on July 16, 2026.
Client #3 was admitted into the partial hospitalization activity on March 31, 2026 and was still active at the time of the inspection. A treatment plan update was completed on June 30, 2026 and the next update was due no later than July 30, 2026; however, the update was completed on August 3, 2026.
Client #4 was admitted into the partial hospitalization activity on August 26, 2024 and was discharged on March 25, 2026. A treatment plan update was completed on December 12, 2025 and the next update was due no later than January 12, 2026; however, the update was completed on February 13, 2026. Additionally, the next treatment plan update was due to be completed no later than March 13, 2026; however, the update was not completed prior to discharge.
Client #5 was admitted into the partial hospitalization activity on June 26, 2025 and was discharged on June 10, 2026. A treatment plan update was completed on December 23, 2025 and the next update was due no later than January 23, 2026; however, the update was completed on February 6, 2026. Additionally, a treatment plan update was completed on April 23, 2026 and the next update was due no later than May 23, 2026; however, the update was not completed prior to discharge.
Client #6 was admitted into the partial hospitalization activity on March 27, 2025 and was discharged on March 3, 2026. A treatment plan update was completed on November 20, 2025 and the next update was due no later than December 20, 2025; however, the update was completed on January 20, 2026. Additionally, a treatment plan update was due to be completed on February 20, 2026; however, the update was not completed until March 3, 2026.
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, Regional Director, Program Director and the VP of Clinical Excellence. Project Transition has re-trained the clinical team on the importance of having the Treatment Plan completed in a timely manner. Additionally, the quality team has implemented a due date in the internal audit sheet. This information will be reviewed in a weekly meeting with the Project Director/ Facility Director, Regional Director, Program Director and VP of Clinical Excellence. A re-training was completed during the Clinical Rounds meeting on 8/27/26. |
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 maintain a complete client record, which is to include the documentation of case consultation notes, in five of seven client records reviewed.
The facility's policy and procedure manual stated case consultations will occur every 60 days.
Client #2 was admitted on December 23, 2025 and was still active at the time of the inspection. Documentation of a case consultation was due to be completed by July 13, 2026; however, the consultation was completed on July 19, 2026.
Client #3 was admitted on March 31, 2026 and was still active at the time of the inspection. Documentation of a case consultation was due to be completed by June 29, 2026; however, the consultation was completed on July 2, 2026.
Client #4 was admitted on August 26, 2024 and was discharged on March 25, 2026. Documentation of a case consultation was due to be completed by January 14, 2026; however, the consultation was completed on February 6, 2026.
Client #5 was admitted on June 26, 2025 and was discharged on June 10, 2026. Documentation of a case consultation was due to be completed by February 3, 2026; however, the consultation was completed on February 20, 2026.
Client #6 was admitted on March 27, 2025 and was discharged on March 4, 2026. Documentation of a case consultation was due to be completed by January 19, 2026; however, the consultation was completed on February 6, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This was reviewed with the Project Director/ Facility Director, Regional Director, Program Director and VP of Clinical Excellence. Project Transition has incorporated the Big Team Note (case consultation) into the weekly Multi-Department Meeting, which involves senior leadership, regional leadership, program leadership as well as others involved in the program operations. We audit and review the Big Team notes audit each week during this meeting to ensure timely completion. A retraining will be completed to ensure the Big Team schedule stays on track and the notes are completed in a timely manner. A re-training was completed during the Clinical Rounds meeting on 8/27/26. This will be re-iterated during the Program Director Quarterly Meeting this fall. The Regional Operations Director will ensure this corrective action is implemented. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to complete an informed and voluntary consent to release information form prior to the disclosure of information was submitted and approved by the Department for the September 27, 2022, August 24, 2023, July 30, 2024, and August 27, 2025 annual licensing inspections. Not completing an informed and voluntary consent to release information form prior to the disclosure of information was again found to be a deficiency in the August 5, 2026 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"Each Corrective Action Plan is reviewed by the President, VP of Outcomes and Systems Development, VP of Program Operations, National Clinical Director and Regional Director to ensure that the plan is able to be accomplished. The Corrective Action Plan will also have a review of 30, 60 and 90 days to ensure the plan has corrected the items. The VP of Outcomes will ensure that this is completed and the results will be reported to the entire Senior Leadership Team. These results will be reported weekly.
This was reviewed with the Project Director/ Facility Director, Regional Director, Program Director and VP of Clinical Excellence. A re-training for release of information was completed duinr the weekly Multi-Department Meeting on 9/2/26. This will be re-iterated during the position specific meetings this fall. The Regional Operations Director will ensure that releases of information are completed timely."
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