INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 19, 2025 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's August 2024 through June 2025 fire drill logs, the facility failed to ensure unannounced fire drills were conducted at least once a month.
At the time of the inspection, there was no docuementation, in the fire drill logs, indicating a fire drill was conducted during the month of September 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director/ Facility Director, Regional Director and Program Director. Project Transition's Fire Drill Form was updated in February 2025 and was re-rolled out and re-trained during the Multi Department Meeting in March 2025. The PT andorra Program Director will ensure that fire drills are conducted on a monthly basis. The Regional Director will review fire drills on a monthly basis to ensure that they are occurring.
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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.
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Observations
Based on a review of the facility's August 2024 through June 2025 fire drill logs, the facility failed to ensure that a fire alarm or a smoke detector was set off during 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 months of January 2025 through June 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed with the Project Director/ Facility Director, Regional Director and Program Director. Due to the office being a shared space, Project Transition is putting an exception request in to be able to use a verbal command to complete a fire drill. If the exception is not granted, the program will warn the others in the shared space of when the smoke detector will be set off as to not cause them alarm.
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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 an administrative review, the facility 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.
At the time of the inspection, there was no financial audit completed for the project's fiscal year ending December 31, 2023.
This is a repeat citation from the September 22, 2022, August 14, 2023, and July 23, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Transition was previously behind by many years on our Financial Audit. The VP of Finance has been working with an auditor to complete all audits and get caught up. Due to the amount of work to get caught up, 2021 and 2022 Financial Audits (submitted) were completed this past year but the 2023 and 2024 audits are still being produced and should be completed by the end of 10/2025 (letter submitted). The VP of Finance is aware and will continue to give updates during weekly Senior Leadership Meetings, where the status and completion of the financial audit will continue to be monitored. |
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 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 eight client records reviewed.
Client # 6 was admitted on October 19, 2023 and was discharged on January 14, 2025. The release of information form to the funding source was signed by the client on October 19, 2023 and expired on October 19, 2024. 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 October 19, 2024.
This finding was 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. Within the Electronic Health Record, the form allows to schedule the next due consent for each entity. This schedule consent will automatically come up on the list of due items for the staff. 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.
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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.
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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, including the documentation of case consultation notes, in four of eight client records reviewed.
The facility's policy and procedure manual stated case consultations will occur every 60 days.
Client # 1 was admitted on February 13, 2025 and was still active at the time of the inspection. A case consultation was due to be completed by April 13, 2025; however, the consultation was completed on May 30, 2025. Additionally, another consultation was due to be completed by July 30, 2025; however, the consultation was completed on August 14, 2025.
Client # 2 was admitted on March 16, 2025 and was still active at the time of the inspection. The last case consultation was documented on May 8, 2025 and the next consultation was due to be completed by July 8, 2025; however, the consultation was completed on August 7, 2025.
Client # 3 was admitted on February 26, 2025 and was still active at the time of the inspection. A case consultation was due to be completed by April 26, 2025; however, the consultation was completed on May 22, 2025. Additionally, another consultation was due to be completed by July 22, 2025; however, the consultation was completed on August 7, 2025.
Client # 4 was admitted on March 13, 2025 and was still active at the time of the inspection. A case consultation was due to be completed by May 13, 2025; however, the consultation was completed on June 5, 2025.
This is a repeat citation from the September 22, 2022, Augsut 14, 2023, and July 23 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Treatment Planning and Big Team process was revamped in the spring of 2025 and trained on 6/26/25. This process includes finalizing the Treatment Plan during the Big Team. Project Transition has also incorporated the Big Team Note (case consultation) into the weekly Multi-Deptartment 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.
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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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to complete an annual financial audit was submitted and approved by the Department for the September 22, 2022, August 14, 2023, and July 23, 2024 annual licensing inspections. Not completing an annual financial audit was again found to be a deficiency in the August 19, 2025 annual licensing inspection.
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, and July 23, 2024 annual licensing inspections. Failing to document case consultation notes every 60 days per facility policy was again found to be a deficiency in the August 19, 2025 annual licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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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. The 30 day review of the CAP will be completed by 10/10/25.
Project Transition was previously behind by many years on our Financial Audit. The VP of Finance has been working with an auditor to complete all audits and get caught up. Due to the amount of work to get caught up, 2021 and 2022 Financial Audits (submitted)were completed this past year but the 2023 and 2024 audits are still being produced and should be completed by the end of 10/2025 (letter submitted). The VP of Finance is aware and will continue to give updates during weekly Senior Leadership Meetings.
The Treatment Planning and Big Team process was revamped in the spring of 2025 and trained on 6/26/25. This process includes finalizing the Treatment Plan during the Big Team. Project Transition has also 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."
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