INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 27, 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 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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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 #6 was admitted to the Partial level of care on July 15, 2021 and was active at the time of the inspection. There was an informed and voluntary consent form to the funding source, signed and dated by the client on July 15, 2021, which expired on July 15, 2022. 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 consnets 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 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in one record reviewed.
Client #6 was admitted to the Partial level of care on July 15, 2021 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the witness on July 26, 2022, that was missing the dated signature of the client.
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 and Facility Director. Based on the review of these findings, all consents will be audited and any consents with missing signatures will be re-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 new system will also notify staff when there is a missing signature on a consent. The Project Director will ensure that all Members have current consents. |
709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the date, event, or condition upon which the consent will expire in one record reviewed.
Client #6 was admitted to the Partial level of care on July 15, 2021 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the witness client on July 26, 2022, that was missing the date, event, or condition upon which the consent will expire.
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 and Facility Director. Based on the review of these findings, all consents will be audited and any consents with missing dates 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 system will also require expiration dates and reasons. 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 two of seven client records reviewed.
Client #1 was admitted to the Partial level of care on February 23, 2021 and was discharged on January 7, 2022. The record contained a consent to release information form to the funding source signed and dated by the client on September 15, 2022 that did not indicate a copy was offered to the client.
Client #6 was admitted to the Partial level of care on July 15, 2021 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 witness on July 26, 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 September 17, 2021 and February 3, 2021 annual licensing inspections.
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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(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 seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in four records reviewed.
Client #2 was admitted on January 27, 2022 and was discharged on August 26, 2022. A treatment plan update was completed on April 15, 2022 and another treatment plan update was due to be completed by May 15, 2022; however, the next treatment plan update was not completed until June 3, 2022.
Client #4 was admitted on April 14, 2022 and was discharged on August 1, 2022. A treatment plan update was completed on May 16, 2022 and a treatment plan update was due to be completed by June 16, 2022; however, the next treatment plan update was not completed until June 24, 2022.
Client #5 was admitted on November 4, 2021 and was active at the time of the inspection. A treatment plan update was completed on January 27, 2022 and a treatment plan update was due to be completed by February 27, 2022, however, the next treatment plan update was not completed until March 4, 2022.
Client #6 was admitted on July 15, 2021 and was active at the time of the inspection. A treatment plan update was completed on December 14, 2021 and a treatment plan update was due to be completed by January 14, 2022, however, the next treatment plan update was not completed until January 24, 2022.
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 Clinical Director. Based on the review of these findings, Project Transition will implement a new Electronic Health Record (EHR) that includes reminder of when Treatment Plans are due on 12/1/22. The system will have reportability to ensure Treatment Plans are completed at least every 30 days. The Clinical Director will ensure that each Member has a Treatment Plan completed at least every 30 days. Until the new system is up and running, the Executive Director of Clinical will review and ensure that Treatment Plans are completed every 30 days. This review will occur during supervision with the clinicians and during Case Consultation.
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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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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 twelve client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring that clients were offered a copy of consent to release information forms was submitted and approved by the Department for the September 17, 2021 and February 3, 2021 annual licensing inspections. Ensuring clients were offered a copy of consent to release information forms was again found to be a deficiency in the September 27, 2022 licensing 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 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 will be re-trained 10/28/22 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. Project Transition is transitioning to a new Electronic Health Record on 12/1/22. The consent document will be built in the EHR and require all necessary elements, such as the Member being offered a copy of the consent. The consent will not be able to be completed or saved without a copy being offered. The Quality Department will monitor that consents are completed correctly at monthly intervals. |