INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 10, 2014 by staff from the Division of Drug and Alcohol 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.
|
Plan of Correction
|
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of personnel records and CPR certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR/First Aid.
The findings include:
Five personnel records and employee CPR certification cards were reviewed on July 10, 2014. The facility has a driver who transports clients alone and that driver currently doesn't have the required CPR/First Aid certifications. The facility failed to ensure that at least one person had current CPR/First Aid certication.
An interview with the facility director on July 10, 2014 confirmed the findings.
|
Plan of Correction
The findings were reviewed by the Facility Director, Training and Development Manager, and the Director of Program Development, Quality and Compliance. The driver was immediately pulled from his duties until he received the appropriate CPR/First Aid Certification training. The driver was given two weeks to get the required training and chose to not follow through and complete the mandatory CPR/First Aid Certification Training. As a result of this the employee was terminated from his position at Project Transition. The facility director will ensure that the new driver will have certification in CPR/First Aid before being able to transport clients.
1. The Training and Development Manager and the Facility Director will ensure that all applicable new hires will complete CPR/First Aid prior to beginning work with clients.
2. This information will be tracked in a central electronic database maintained by the Training and Development Manager.
3. The Training and Development Manger will work in collaboration with the Facility director to identify and/or provide regular CPR/First Aid Trainings for staff.
Responsible Party: Facility Director, Training and Development Manager |
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.
|
Observations
Based on a review of the project's administrative documentation, the project failed to complete an annual report to include a financial statement of income and expenses for the fiscal year 2013.
The findings included:
The administrative documentation was reviewed on July 10, 2014. The annual report is to include a financial statement of income and expenses. The project failed to include the financial statement of income and expenses in the 2013 annual report.
An interview with the Director of Program Development, Quality, and Compliance on July 10, 2014 confirmed the findings.
|
Plan of Correction
The findings were reviewed by the Director of Program Development, Quality and Compliance, Vice President of Quality and Program Fidelity, and the Chief Financial Officer. The financial statement of income and expenses was added to the Annual Report for fiscal year 2013 by the Chief Financial Officer.
Plan to ensure deficiency does not recur:
1. The Vice President of Quality and Program Fidelity will produce and sign off on the Annual Report and ensure that the financial statement including income and expenses is included
2. The Chief Financial Officer will review the Annual Report for accurancy before it is released.
3. The Director of Program Development, Quality and Compliance will do a final review of the Annual Report to ensure that all elements (including the financial statement) are included in the Annual Report.
Responsible Party: Chief Financial Officer, Director of Program Development, Quality and Compliance, Vice President of Quality and Program Fidelity |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical/psych coverage.
The findings include:
The letters of agreement were reviewed on July 10, 2014. The facility documented a letter of agreement signed in February 2013. The letter of agreement failed to have documented whether the hospital had 24 hour emergency medical/psych coverage.
An interview with facility and corporate staff on July 10, 2014 confirmed the findings.
|
Plan of Correction
The findings were reviewed by the Facility Director and the Director of Program Development, Quality and Compliance. A new standard letter of agreement form was drafted to include specific language stating that the facility provides 24 hour emergency medical/psych coverage. The Director of Program Development, Quality, and Compliance identified key individuals at each hospital/facility to sign the new letters of agreement. The letters were sent out for signature to each facility on 8/31/14. The signed letters of agreement will be in place by 10/01/14.
Plan to ensure deficiency does not recur:
1. The Director of Program Development Quality and Compliance has created a standard form for the letters of agreement that will be used without exception moving forward.
2. The Director of Program Development, Quality and Compliance will maintain a paper and electronic copy of all letters of agreement.
3. The Director of Program Development, Quality and Compliance will maintain a spreadsheet to track expiration dates of letters of agreement.
4. The Director of Program Developement, Quality and Compliance will track and update letters of agreement when needed (every two years).
Responsible Party: Director of Program Development, Quality and Compliance. |