INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on March 30, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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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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 document that fire extinguisher training was provided upon employment in two of two personnel records.
The findings include:
On March 30, 2012, two personnel records were reviewed for documentation of fire extinguisher training, specifically records # 2 and 3. The facility did not document that fire extinguisher training was provided upon employment in personnel records # 2 and 3.
Personnel # 2 was hired for his current position on 12/1/06, but verification of this training was not documented until 1/19/12.
Personnel # 3 was hired for his current position on 1/1/12, but verification of this training was not documented at the time of review on 3/30/12.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
Employee # 3 received fire extinguisher training on 4/12/2012.
The Facilities/Fleet Manager will ensure that each employee is provided documented fire extinguisher training upon employment. The Director of Quality Improvement will audit personnel and training files to verify that the training has been completed.
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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 document that all personnel are trained to perform assigned task during emergencies in two of two personnel records.
The findings include:
On March 30, 2012, two personnel records were reviewed for documentation of emergency training. The facility did not document that emergency training was provided upon employment in personnel records # 2 and 3.
Personnel # 2 was hired for his current position on 12/1/06, but verification of this training was not documented until 1/19/12.
Personnel # 3 was hired for his current position on 1/1/12, but verification of this training was not documented at the time of review on 3/30/12.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
The Facilities/Fleet Manager will ensure that each employee is provided a documented emergency training upon employment prior to them working at a program site. The Director of Quality Improvement will audit personnel and training files to verify that the training has been completed
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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 a medical history in four out of four records.
The findings include:
On March 30, 2012, four client records were reviewed for medical histories, specifically records # 1, 2, 3 and 4. The facility did not document a medical history in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 1/1/12. Client # 1 ' s record did not contain a medical history.
Client # 2 was admitted on 1/1/12. Client # 2 ' s record did not contain a medical history.
Client # 3 was admitted on 1/1/12. Client # 3 ' s record did not contain a medical history.
Client # 4 was admitted on 1/1/12. Client # 4 ' s record did not contain a medical history.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
Clients 1, 2, 3, & 4 will have updated medical history completed by 5/15/2012
The Program Director will ensure that each member has a full updated Medical History completed on any new member or member newly admitted to the D& A program within 30 days of admission. Each history will be signed and dated. The Quality Department will audit members chart to ensure that an updated Medical History is completed. |
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 a drug and alcohol history in four out of four records.
The findings include:
On March 30, 2012, four client records were reviewed for drug and alcohol histories, specifically records # 1, 2, 3 and 4. The facility did not document a drug and alcohol history in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 1/1/12. Client # 1 ' s record contained a drug and alcohol history, but the drug and alcohol history was not signed or dated. It was not possible to determine when the drug and alcohol history was completed.
Client # 2 was admitted on 1/1/12. Client # 2 ' s record did not contain a drug and alcohol history.
Client # 3 was admitted on 1/1/12. Client # 3 ' s record contained a drug and alcohol history, but the drug and alcohol history was not signed or dated. It was not possible to determine when the drug and alcohol history was completed.
Client # 4 was admitted on 1/1/12. Client # 4 ' s record contained a drug and alcohol history, but the drug and alcohol history was not signed or dated. It was not possible to determine when the drug and alcohol history was completed.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
Drug and Alcohol history will be reviewed signed and dated by the clinician and client by 5/15/12 for client records 1, 3 & 4
Client Record 2 a Drug and alcohol history will be completed by 5/15/12
The Program Director will ensure that each member has a full updated Drug and Alcohol History completed on any new member or member newly admitted to the D& A program within 30 days of admission. Each history will be signed and dated. The Quality Department will audit members chart to ensure that an updated Drug and Alcohol History is completed. |
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 a personal history in four out of four records.
The findings include:
On March 30, 2012, four client records were reviewed for personal histories, specifically records # 1, 2, 3 and 4. The facility did not document a personal history in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 1/1/12. Client # 1 ' s record did not contain a personal history.
Client # 2 was admitted on 1/1/12. Client # 2 ' s record did not contain a personal history.
Client # 3 was admitted on 1/1/12. Client # 3 ' s record did not contain a personal history.
Client # 4 was admitted on 1/1/12. Client # 4 ' s record did not contain a personal history.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
Clients 1, 2, 3, & 4 will have personal history completed by 5/15/2012
The Program Director will ensure that each member has a full updated Personal History completed on any new member or member newly admitted to the D& A program within 30 days of admission. Each history will be signed and dated. The Quality Department will audit members chart to ensure that an updated Personal History is completed. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a psychosocial evaluation in four out of four records.
The findings include:
On March 30, 2012, four client records were reviewed for psychosocial evaluations, specifically records # 1, 2, 3 and 4. The facility did not document a psychosocial evaluation in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 1/1/12. Client # 1 ' s record did not contain a psychosocial evaluation.
Client # 2 was admitted on 1/1/12. Client # 2 ' s record did not contain a psychosocial evaluation.
Client # 3 was admitted on 1/1/12. Client # 3 ' s record did not contain a psychosocial evaluation.
Client # 4 was admitted on 1/1/12. Client # 4 ' s record did not contain a psychosocial evaluation.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
Clients 1, 2, 3, & 4 will have a Psychosocial Evaluation completed by 5/15/2012
The Program Director will ensure that each member has a Psychosocial Evaluation completed on any new member or member newly admitted to the D& A program within 30 days of admission. Each evaluation will be signed and dated. The Quality Department will audit members chart to ensure that a Psychosocial Evaluation is completed.
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709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of client records, the facility failed to document an individual treatment plan in four out of four records.
The findings include:
On March 30, 2012, four client records were reviewed for individual treatment plans, specifically records # 1, 2, 3 and 4. The facility did not document a individual treatment plan in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 1/1/12. Client # 1 ' s record did not contain an individual treatment plan.
Client # 2 was admitted on 1/1/12. Client # 2 ' s record did not contain an individual treatment plan.
Client # 3 was admitted on 1/1/12. Client # 3 ' s record did not contain an individual treatment plan.
Client # 4 was admitted on 1/1/12. Client # 4 ' s record did not contain an individual treatment plan.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
The Program Director will ensure that each member has a full Treatment Plan completed on any new member or member newly admitted to the D& A program within 30 days of admission. The Quality Department will audit members chart to ensure that a new Treatment Plan is completed.
This was done for clients 1,2,3,& 4 before or on 5/1/2012 |
709.82(e)(3) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(3) Legal.
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Observations
Based on a review of administrative records, the facility failed to document resources for assisting clients in obtaining legal services.
The findings include:
On March 30, 2012, the facility ' s letters of agreements were reviewed. The facility did not have a written letter of agreement or understanding with a referral source to assist clients in obtaining legal services.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
The Director of Quality Improvement will obtain an updated letter of agreement for legal services in Philadelphia County by 6/1/12. The Director of Quality Improvement will develop a tracking sheet by 6/1/12 for all letters of agreement to ensure that they are completed within the specified timeframe. |
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 administrative records, the facility failed to make available to the public an annual report.
The findings include:
On March 30, 2012, the facility ' s administrative records were reviewed for documentation of their annual report ' s availability to the public. The facility did not notify the public about their 2011 annual report.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
The Director of Community Relations and Marketing posted the information regarding the availability of public viewing of the annual report on the Project Transition website on 5/1/12. The Director of Community Relations and Marketing will post the information upon completion of the annual report each year moving forward. |
709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
Based on a review of administrative records, the facility failed to document an annual report to include a financial statement of income and expenses.
The findings include:
On March 30, 2012, the facility ' s 2011 annual report was reviewed. The 2011 annual report did not include a financial statement of income and expenses.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
The 2011 Annual Report will be revised by the Chief Executive Officer to include a financial statement of income and expenses by 5/15/12.
The Director of Quality Improvement will review annual report prior to it being finalized to ensure that it includes a financial statement of income and expenses before it is finalized, on an annual basis. |
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 March 30, 2012, the facility ' s administrative records were reviewed for documentation of an annual audit of financial activities. The facility did not document a financial audit for the 2010 fiscal year.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
The Senior Director of Admissions and Administration and the Chief Executive Officer will work with an independent public accountant to document an annual audit of financial activities by 6/1/12. In order to prevent this deficiency from occurring again, The Chief Financial Officer will work with an independent public accountant to ensure that an annual audit of financial activities is completed. |
709.26(e)(1) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(1) The employe's right to inspect his own records.
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Observations
Based on the review of personnel records, the facility failed to demonstrate efforts toward informing staff of the right to inspect their own record in two of two personnel records.
The findings include:
On March 30, 2012, two personnel records were reviewed for notification to staff of the right to inspect his record, specifically records # 2 and 3. The facility did not document that employees were informed of the right to inspect their own record in personnel records # 2 and 3.
An interview with the Director of Quality Improvement on March 30, 2012 confirmed the findings.
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Plan of Correction
The Director of Quality Improvement will work with the Manager of HR and Training to revise the paperwork provided to staff to include the right to inspect his/her own record by 5/1/12.
Project Transition has updated its current staff files so they have the current form in them. All old forms will be disposed of to ensure that this does not reoccur.
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