INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from June 19, 2012, by staff from the Division of Drug and Alcohol 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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705.1 (3) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
Based upon the physical plant inspection and review of administrative documentation, the facility failed to verify compliance with local laws and ordinances.
The findings include:
Administrative documentation was reviewed on June 19, 2012, and a physical plant inspection was conducted on June 19, 2012, from approximately 10:30 - 11:00 AM.
During the physical plant inspection, the Licensing Specialist did not see a copy of a posted zoning permit. Additionally, there was no copy of a zoning permit included in the administrative documentation that verified that the business was appropriate for the zoning classification.
The findings were confirmed by the Director of Quality Improvement during the exit interview.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that the hours of project operation were displayed conspicuously to the general public.
The findings include:
The physical plant inspection was conducted on June 19, 2012, between the hours of 10:30 to 11:00 AM. The hours of operation for the program were not displayed for the general public to view.
The Facility Director confirmed the findings during the exit interview.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that a telephone number was displayed conspicuously to the general public for emergency purposes.
The findings include:
The physical plant inspection was conducted on June 19, 2012, between the hours of 10:30 to 11:00 AM. The telephone number for the program were not displayed for the general public to view.
The Facility Director confirmed the findings during the exit interview.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 upon a review of the Staffing Requirements Facility Summary Report (SRFSR) and employee rights sign-offs, the facility failed to demonstrate that two of two employees were informed of their right to inspect their own record.
The findings include:
Licensing Staff conducted an on-site inspection on June 19, 2012. At the time of inspection, the facility did not have a copy of the P&P Manual on-site, was unable to complete the SRFSR, and did not have access to employee records. However, the Director of Quality Improvement (DQI) was able to access a limited portion of the facility's P&P via a laptop computer that was brought to the site during the inspection.
On June 20, 2012, the DQI forwarded a copy of the SRFSR to the Licensing Specialist. A review of the SRFSR revealed that two new counselors, employee #'s 1 and 2, were hired since the last inspection.
Employee # 1 was hired on January 9, 2012, and employee # 2 was hired on April 2, 2012. On June 21, 2012, the Licensing Specialist requested that the DQI forward documentation that demonstrated that employee #'s 1 and 2 were informed of their right to inspect their own record. However, the documentation that was forwarded for both employees, via e-mail, did not demonstrate that either one was informed of their right.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(e)(2) 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:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based upon a review of the Staffing Requirements Facility Summary Report (SRFSR) and employee rights sign-offs, the facility failed to demonstrate that two of two employees were informed of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
The findings include:
Licensing Staff conducted an on-site inspection on June 19, 2012. At the time of inspection, the facility did not have a copy of the P&P Manual on-site, was unable to complete the SRFSR, and did not have access to employee records. However, the Director of Quality Improvement (DQI) was able to access a limited portion of the facility's P&P via a laptop computer that was brought to the site during the inspection.
On June 20, 2012, the DQI forwarded a copy of the SRFSR to the Licensing Specialist. A review of the SRFSR revealed that two new counselors, employee #'s 1 and 2, were hired since the last inspection.
Employee # 1 was hired on January 9, 2012, and employee # 2 was hired on April 2, 2012.
On June 21, 2012, the Licensing Specialist requested that the DQI forward documentation that demonstrated that employee #'s 1 and 2 were informed of their right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records. However, the documentation that was forwarded for both employees, via e-mail, did not demonstrate that either one was informed of their right.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(e)(3) 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:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
Based upon a review of the Staffing Requirements Facility Summary Report (SRFSR) and employee rights sign-offs, the facility failed to demonstrate that two of two employees were informed of their right to submit rebuttal data or memoranda to his own records.
The findings include:
Licensing Staff conducted an on-site inspection on June 19, 2012. At the time of inspection, the facility did not have a copy of the P&P Manual on-site, was unable to complete the SRFSR, and did not have access to employee records. However, the Director of Quality Improvement (DQI) was able to access a limited portion of the facility's P&P via a laptop computer that was brought to the site during the inspection.
On June 20, 2012, the DQI forwarded a copy of the SRFSR to the Licensing Specialist. A review of the SRFSR revealed that two new counselors, employee #'s 1 and 2, were hired since the last inspection.
Employee # 1 was hired on January 9, 2012, and employee # 2 was hired on April 2, 2012.
On June 21, 2012, the Licensing Specialist requested that the DQI forward documentation that demonstrated that employee #'s 1 and 2 were informed of their right to submit rebuttal data or memoranda to his own records. However, the documentation that was forwarded for both employees, via e-mail, did not demonstrate that either one was informed of their right.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |