INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 1, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Project Transitions, 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and staff schedules for the month of August 2017, the facility failed to demonstrate sufficient coverage of staff certified in CPR or First Aid during the 4:30 P.M. through 09:00 P.M. shift on the following dates:
August 9, 2017
August 16, 2017
August 23, 2017
August 30, 2017
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 Human Resources and Training Manager. Based on the review of these findings, the Human Resources and Training Manager has reviewed all employee records and confirmed which employees have a current CPR/First Aid Certification. The Human Resources and Training Manager will ensure that a copy of all employee's CPR/First Aid Certification is placed in their chart by 9/30/17. The Human Resources and Training Manager has informed the Facility Director, who will ensure that each scheduled shift has at least one staff person with a current CPR/First Aid Certification. To prevent this issue from occurring int he future, a copy of each employee's current CPR/First Aid Certification will be required within the first 30 days of the employee's employment. Until the copy of the current CPR/First Aid Certification is obtained, the Facilty Director will only schedule the employee with another employee that has a current CPR/First Aid Certification. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
A review of the August 2016 through July 2017 fire drill logs was conducted during the inspection process. Each log, except for the month of April 2017, indicated that the front door was used as the exit route during the fire drill, indicating that the facility failed to prepare alternate routes. The log for the month of April 2017 failed to include the specific exit route used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Director of Facilities, the Project Director and the Facilty Director. Based on the review of these findings, the Director of Facilities will number the emergency exits. During fire drills, it will be documented which number exit was used instead of stating "front", "side" or "back". This will alleviate any confusion as to what to document as the exit being used. This will be monitored and tracked by the Director of Facilities. |
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 documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Director of Finance and the CEO. Project Transition is currently engaged with an outside accounting firm who has conducted an independent financial audit. The results of this audit have been completed as of 9/27/17. Project Transition will continue to have an independent financial audit yearly. The Director of Finance will ensure that the audit will be started earlier to ensure that it has been completed within 6 months of the following year. |
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 a review of five personnel records, the facility failed to ensure that personnel records contained documentation of an employee-signed, annual written individual performance evaluation in one employee record.
Employee # 3 had been employed since 8/10/11 and as a clinical supervisor since 2015. The annual employee evaluation, dated 3/15/17, was not signed by the employee.
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 Human Resources and Training Manager. Based on the review of these findings, the Human Resources and Training Manager has reviewed all employee records and confirmed which employees have not had an annual performance evaluation. All employees without annual performance evaluations will have them completed by 10/15/17. To prevent this issue from occurring in the future, the Human Resources and Training Manager will ensure that the annual performance evaluations are entered into Project Transition's Relias E-Learning system. The Facility Director and employee will receive notification within 30 days of the annual performance evaluation being due. This will be monitored and tracked by the Human Resources and Training Manager. |
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 seven client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one client record. Additionally, two client records had consent to release information forms that were missing required components.
Client #2 was admitted on 8/25/16 and was discharged on 10/22/16. The record documented consent to release information forms to another treatment provider and an unidentified recipient, signed by the client on 8/19/16, but not signed by a witness until 8/22/16.
Client #3 was admitted on 5/28/13 and was discharged on 5/22/17. The record did not contain a consent to release information form to the funding source at the time of the inspection and there was evidence of disclosure of information.
Client #5 was admitted on 3/1/17 and was an active client at the time of inspection. The record contained a consent to release information form to a family member, dated 4/7/17, which was not signed by the client.
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. Based on the review of these findings, the Quality and Outcomes Manager has audited all member consents. New consents are to be completed for any consents that are expired or have any other deficiencies by 10/15/17. To prevent this issue from occurring in the future, the Quality and Outcomes Manager will conduct a re-training that covers the importance of obtaining consent as well as the proper way to fill out the consent forms will occur with staff on 10/11/17 and 10/12/17. This will be monitored and tracked by the Project Director. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on the review of the facility's unusual incident reports and client records, the facility failed to notify the Department within the regulatory timeframe following the unusual incidents below, which were discovered during the licensing process.
The incident dates and incident reasons were:
July 8, 2017 - Facility informed of the death of a client
February 9, 2017- Facility informed of the death of a client
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. Based on the review of these findings, the two incidents in question were reported to the Department on 10/6/17. Project Transition's Incident Management Process will be updated to include the notification of death, serious injury due to trauma, suicide, medication error or unusual circumstances regardless of where the incident occurred. Project Transition's Quality and Outcomes Manager will file a written unusual incident report with the Department within 3 business days following an unusual incident. This will be monitored and tracked by the Quality and Outcomes Manager. |
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 six client records, two records had treatment plan updates completed after the regulatory timeframe.
Client #5 was admitted on 3/1/17 and was an active client at the time of inspection. The comprehensive treatment and rehabilitation plan was completed on 5/3/17 and treatment plan updates for 5/31/17, 6/30/17, and 7/30/17 were completed on 8/24/17.
Client #7 was admitted on 11/16/16 and was an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on 1/27/17 and treatment plan updates for 1/15/17 and 2/14/17 were completed on 4/11/17, the treatment plan update for 3/16/17 was completed on 5/3/17, and treatment plan updates for 5/14/17, 6/14/17, and 7/14/17 were completed on 8/31/17.
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 Vice President of Clinical Services. Based on the review of these findings, the Clinicians will take over the completion of the Treatment Plan under the supervision of the Vice President of Clinical Services. To prevent this issue from occurring in the future, the Facility Director will ensure that the completion of all Treatment Plans will be audited on a weekly basis. This will be monitored and tracked by the Project Director. |