INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20-21, 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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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:
Three personnel records requiring documentation of fire extinguisher training were reviewed on August 20, 2012, specifically records # 3, 4 and 5. The facility did not document that fire extinguisher training was provided upon employment in personnel records # 3, 4 and 5.
Employee # 3 was hired on 1/15/11, but verification of fire extinguisher training was not documented until 11/21/11.
Employee # 4 was hired on 5/29/12, but verification of fire extinguisher training was not documented until 6/14/12.
Employee # 5 was hired on 10/11/11, but verification of fire extinguisher training was not documented until 3/20/12.
The findings were confirmed by the Director of Quality Improvement on August 20, 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.
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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:
Three personnel records requiring documentation of emergency training were reviewed on August 20, 2012, specifically records # 3, 4 and 5. 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. One out of the three records reviewed did not contain documentation that the employee had been trained to perform assigned task during emergencies, specifically in record # 4.
Employee # 4 was hired on 5/29/12, but verification of emergency training was not documented until 6/14/12.
The findings were confirmed by the Director of Quality Improvement on August 20, 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. |
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:
Five client records requiring medical histories were reviewed on August 21, 2012, specifically records # 1, 2, 3, 4 and 5. The facility did not document a medical history within 30 days, as per facility policy, in records # 1, 2, 3, 4 and 5.
Client # 1 was admitted to the facility's Addiction Recovery Track on 6/18/12, but client # 1's record did not contain an updated medical history at the time of review on 8/21/12.
Client # 2 was admitted to the facility's Addiction Recovery Track on 7/23/12, but client # 2's record did not contain an updated medical history at the time of review on 8/21/12.
Client # 3 was admitted to the facility's Addiction Recovery Track on 6/14/12, but client # 3's record did not contain an updated medical history at the time of review on 8/21/12.
Clients # 4 & 5 were both admitted to the facility's Addiction Recovery Track on 1/1/11, but client records # 4 and 5 did not contain an updated medical history at the time of review on 8/21/12.
The findings were confirmed by the Director of Quality Improvement on August 21, 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)(ii) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records, the facility failed to document drug and alcohol histories.
The findings include:
Five client records requiring drug and alcohol histories were reviewed on August 21, 2012, specifically records # 1, 2, 3, 4 and 5. The facility did not document a drug and alcohol history within 30 days, as per facility policy, in records # 1, 3, 4 and 5.
Client # 1 was admitted to the facility's Addiction Recovery Track on 6/18/12, but client # 1's record did not contain an updated drug and alcohol history at the time of review on 8/21/12.
Client # 3 was admitted to the facility's Addiction Recovery Track on 6/14/12, but client # 3's record did not contain an updated drug and alcohol history at the time of review on 8/21/12.
Clients # 4 & 5 were both admitted to the facility ' s Addiction Recovery Track on 1/1/11, but client records # 4 and 5 did not contain an updated drug and alcohol history at the time of review on 8/21/12.
The findings were confirmed by the Director of Quality Improvement on August 21, 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 drug and alcohol 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 drug and alcohol 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:
Five client records requiring personal histories were reviewed on August 21, 2012, specifically records # 1, 2, 3, 4 and 5. The facility did not document a personal history within 30 days, as per facility policy, in records # 1, 2, 3, 4 and 5.
Client # 1 was admitted to the facility's Addiction Recovery Track on 6/18/12, but client # 1's record did not contain an updated personal history at the time of review on 8/21/12.
Client # 2 was admitted to the facility's Addiction Recovery Track on 7/23/12, but client # 2's record did not contain an updated personal history at the time of review on 8/21/12.
Client # 3 was admitted to the facility's Addiction Recovery Track on 6/14/12, but client # 3's record did not contain an updated personal history at the time of review on 8/21/12.
Clients # 4 & 5 were both admitted to the facility ' s Addiction Recovery Track on 1/1/11, but client records # 4 and 5 did not contain an updated personal history at the time of review on 8/21/12.
The findings were confirmed by the Director of Quality Improvement on August 21, 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:
Three client records requiring treatment plan updates were reviewed on August 21, 2012, specifically records # 1, 3 and 4. The facility did not document a treatment plan update to include an assessment of the client's progress in records # 1 and 4.
Client # 1 was admitted to the facility's Addiction Recovery Track on 6/18/12. The treatment plan update in client # 1's record dated 8/16/12 did not include an assessment of progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 4 was admitted to the facility's Addiction Recovery Track on 1/1/11. The treatment plan updates in client # 4 ' s record dated 1/16/12, 2/16/12 and 3/4/12 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 21, 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)(6) 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:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of client records, the facility failed to document aftercare plans that included future goals with timeframes and the criteria for re-entry into the program.
The findings include:
Two client records requiring documentation of aftercare plans were reviewed on August 21, 2012, specifically records # 4 and 5. The facility did not document aftercare plans that included future goals with timeframes and the criteria for re-entry in records # 4 and 5.
Client # 4 was admitted to the program on 1/1/11 and discharged on 8/1/12. The aftercare plan in client # 4's record dated 3/27/12 did not include future goals with timeframes and the criteria for re-entry.
Client # 5 was admitted to the program on 1/1/11 and discharged on 7/18/12. The aftercare plan in client # 5's record dated 7/16/12 did not include future goals with timeframes and the criteria for re-entry.
The findings were confirmed by the Director of Quality Improvement on August 21, 2012.
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Plan of Correction
Project Transition is changing it's after care form to include the criteria for reentry into the drug and alcohol program after discharge, as well as future goals with time frmes. This form will be updated by 10/1/2012. Ongoing all after care forms will contain criteria for reentry to the program, this will be audited by the quality improvement team. |
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 the review of client records, the facility failed to document follow-up information.
The findings include:
Two client records requiring documentation of follow-up were reviewed on August 21, 2012, specifically records # 4 and 5. The facility did not document follow-up information in client records # 4 and 5.
Client # 4 was admitted to the program on 1/1/11 and discharged on 8/1/12. Client # 4's record did not include follow-up information at the time of review on 8/21/12.
Client # 5 was admitted to the program on 1/1/11 and discharged on 7/18/12. Client # 5's record did not include follow-up information at the time of review on 8/21/12.
The findings were confirmed by the Director of Quality Improvement on August 21, 2012.
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Plan of Correction
Beginning immediately, staff will document follow up with the member up to 30 days post discharge from the Drug and Alcohol program. This documentation will be filled in the discharge section of the clinical chart and audited by the quality improvement team. |
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:
August 20, 2012, the facility's administrative records were reviewed for documentation of the availability of their annual report 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 20, 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 20, 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 20, 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. |
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:
Four personnel records requiring documentation of a performance evaluation were reviewed on August 20, 2012, specifically records # 1, 2, 3 and 5. The facility did not document a performance evaluation at the completion of the first six months of employment and annually thereafter, as per facility policy, in personnel records # 1 and 5.
Personnel # 1 was hired on 8/1/87. Personnel # 1's record did not contain a performance evaluation at the time of review on 8/20/12.
Personnel # 5 was hired on 10/10/11. Personnel # 5's record did not contain a performance evaluation at the time of review on 8/20/12.
The findings were confirmed by the Director of Quality Improvement on August 20, 2012.
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Plan of Correction
The current year's performance evaluations for staff #1 and #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. |