INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 27, 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, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the facility's October 2025 through May 2026 fire drill logs, the facility failed to ensure that a fire alarm or smoke detector was set off during the fire drills.
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 October 2025 and during the months of January 2026 through April 2026.
This is a repeat citation from the August 19, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
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.
|
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 #5 was admitted into the partial hospitalization activity on June 25, 2024 and was discharged on June 10, 2026. The release of information form to the funding source was signed by the client on June 25, 2024 and expired on June 25, 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 June 25, 2025.
This is a repeat citation from the August 19, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
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 funtion 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.
|
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 three of seven applicable client records reviewed.
Client #4 was admitted into the partial hospitalization activity on July 31, 2024 and was discharged on June 3, 2026. A treatment plan update was completed on November 5, 2025 and the next update was due no later than December 5, 2025; however, the update was completed on December 9, 2025. Additionally, an update was completed on April 7, 2026 and the next update was due no later than May 7, 2026; however, the update was completed on May 13, 2026.
Client #5 was admitted into the partial hospitalization activity on June 25, 2024 and was discharged on June 10, 2026. A treatment plan update was completed on April 7, 2026 and the next update was due no later than May 7, 2026; however, the update was completed on May 13, 2026.
Client #7 was admitted into the partial hospitalization activity on March 14, 2025 and was discharged on July 28, 2026. A treatment plan update was completed on January 28, 2026 and the next update was due on February 28, 2026; however, the update was completed on March 3, 2026.
These findings were reviewed with facility staff during the licensing process.
|
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.
|
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 four of six applicable client records reviewed.
The facility's policy and procedure manual stated that case consultations will occur every 60 days.
Client #2 was admitted on January 12, 2026 and was still active at the time of the inspection. A case consultation was due to be completed by March 29, 2026; however, the consultation note indicated the consult was completed on April 16, 2026.
Client #4 was admitted on July 31, 2024 and was discharged on June 3, 2026. A case consultation was due to be completed by December 9, 2025; however, the consultation note indicated the consult was completed on December 18, 2025. Additionally, another consultation was due to be completed on May 5, 2026; however, the consultation note indicated the consult was completed on June 3, 2026.
Client #6 was admitted on February 26, 2025 and was discharged on February 25, 2026. A case consultation was due to be completed by December 9, 2025; however, the consultation note indicated the consult was completed on January 8, 2026.
Client #7 was admitted on March 14, 2026 and was discharged on July 8, 2026. A case consultation was due to be completed by February 13, 2026; however, the consultation note indicated the consult was completed on February 19, 2026. Additionally, another consultation was due to be completed on May 5, 2026; however, the consultation note indicated the consult was completed on May 7, 2026.
This is a repeat citation from the September 22, 2022, August 14, 2023, July 23, 2024 and August 19, 2025 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
|
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.
|
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 document case consultation notes every 60 days, per facility policy, was submitted and approved by the Department for the September 22, 2022, August 14, 2023, July 23, 2024, and August 19, 2025 annual licensing inspections. Failing to document case consultation notes every 60 days, per facility policy, was again found to be a deficiency in the July 27, 2026 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
|
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. 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 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.
|