INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29, 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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704.6(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 clinical supervisors participate in monthly meetings with their supervisors for the first six months of employment in one applicable record reviewed.
Employee # 3 was hired as the clinical supervisor on June 23, 2022. No supervision meetings were documented as of the date of the 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 Clinical Director as well as the CEO. Supervisions were happening frequently, however, there were no documented supervisions. The Clinical Director will ensure that all supervisions are documented effective immediately. Staff files will be audited by the VP of Human Resources on a quarterly basis to ensure documented supervision is occurring. |
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:
30/40 = 0.75(FTE); 15/0.75 = 20, which equals to a client/counselor ratio of 20:1.
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 contunue 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.
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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 four of six appliable records reviewed and failed to follow their policy related to preliminary treatment plans completed within 24 hours of admission in two of six applicable records reviewed.
Client #4 was admitted to the Partial level of care on November 4, 2021 and was discharged on May 27, 2022. There was no documentation of a case consultation by December 4, 2021.
Client #5 was admitted to the Partial level of care on January 18, 2022 and was active at the time of the inspection. There was no documentation of a case consultation by February 18, 2022.
Client #6 was admitted to the Partial level of care on March 24, 2022 and was active at the time of the inspection. There was no documentation of a case consultation by April 24, 2022. Additionally, a preliminary treatment plan was due to be completed by March 25, 2022, however, it was not completed until May 16, 2022.
Client #7 was admitted to the Partial level of care on May 31, 2022 and was active at the time of the inspection. There was no documentation of a case consultation by July 1, 2022. Additionally, a preliminary treatment plan was due to be completed by June 1, 2022, however, it was not completed until June 14, 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 Heatlh 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.
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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.
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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 obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in one record reviewed.
Client #2 was admitted to the Partial level of care on October 23, 2019 and was discharged on October 18, 2021. There was an informed and voluntary consent form to the funding source, signed and dated by the client on August 11, 2020, which expired on August 11, 2021. There was documentation of billing after the expiration date and there was no updated consent form signed by the client documented in the record prior to the disclosures.
The findings were discussed 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. Based on the review of these findings, all consents will be audited and any missing consents will be created and signed by both the staff and Member by 10/31/22. To prevent this issue from occurring in the future, Project Transition is implementing a new Electronic Health Record (EHR) with workflows that will remind staff when a consent is close to expiring to ensure there is no gap. The Project Director will ensure that all Members have current consents.
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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 five of seven client records reviewed.
Client #3 was admitted to the Partial level of care on July 28, 2021 and was discharged on July 5, 2022. The record contained a consent to release information form to the funding source signed and dated by the client on July 28, 2022 that did not indicate a copy was offered to the client.
Client #4 was admitted to the Partial level of care on November 4, 2021 and was discharged on May 27, 2022. The record contained a consent to release information form to the funding source signed and dated by the client on November 4, 2021 that did not indicate a copy was offered to the client.
Client #5 was admitted to the Partial level of care on January 18, 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 January 28, 2022 that did not indicate a copy was offered to the client.
Client #6 was admitted to the Partial level of care on March 24, 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 24, 2022 that did not indicate a copy was offered to the client.
Client #7 was admitted to the Partial level of care on May 31, 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 May 31, 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 February 4, 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.
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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 four records reviewed.
Client #3 was admitted on July 28, 2021 and was discharged on July 5, 2022. The record of service and progress notes indicated that the client received only one session each of the following weeks: April 25, 2022, May 2, 2022, May 23, 2022, May 30, 2022, June 6, 2022, June 20, 2022, and June 27, 2022.
Client #5 was admitted on January 18, 2022 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 August 15, 2022 and June 13, 2022, and only one session each of the following weeks: February 7, 2022 and February 14, 2022.
Client #6 was admitted on March 24, 2022 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 April 4, 2022 and April 25, 2022 and only one session each of the following weeks: August 1, 2022, August 15, 2022, August 25, 2022, June 6, 2022, April 11, 2022.
Client #7 was admitted on May 31, 2022 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 week of July 4, 2022, and only received one session each of the following weeks: July 25, 2022, June 6, 2022, and June 27, 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.
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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 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 an aftercare plan in two of four applicable records reviewed.
Client #1 was admitted on September 14, 2021 and was discharged on April 23, 2022. The client record did not contain documentation of a completed aftercare plan.
Client #4 was admitted on November 4, 2021 and was discharged on May 27, 2022. The client record did not contain documentation of a completed aftercare plan.
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 an the Facility Director. Based on the review of these findings, to prevent this issue from occurring in the future, Project Transition is adding the completion of the After Care Plan (APPLE - Plan) to the Social Worker's KPI Supervision Document. The Project Director will ensure that each Member who leave the program has a completed After Care Plan.
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709.83(a)(10) 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:
(10) Discharge summary.
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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 a discharge summary in two of four applicable records reviewed.
Client #1 was admitted on September 14, 2021 and was discharged on April 23, 2022. The client record did not contain documentation of a completed discharge summary.
Client #4 was admitted on November 4, 2021 and was discharged on May 27, 2022.The client record did not contain documentation of a completed discharge summary.
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 an the Facility Director. Based on the review of these findings, to prevent this issue from occurring in the future, Project Transition is adding the completion of the Discharge Summary (APPLE - Leave) to the Social Worker's KPI Supervision Document. The Project Director will ensure that each Member who leave the program has a completed Discharge Summary.
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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.
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