INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24, 2023, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records and a discussion with facility staff, the facility failed to provide documentation that the clinical supervisor participated in monthly meetings with their supervisor for the first six months of employment in one applicable record reviewed.
Employee # 2 was promoted to clinical supervisor on March 17, 2022. Although this employee's date of promotion was prior to the previous inspection, they were not identified as a clinical supervisor during the previous inspection, thus their credentials were not reviewed. No supervision meetings were documented for the employee's first six months of employment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Transition's Clinical Supervisor did not have supervision notes. We do have a new Executive VP of Clinical and Program Operations. She will ensure that notes are taken during supervision. Project Transition has created a new KPI document that looks at supervision at least monthly and is tracked by the Project Director on a monthly basis. This will be monitored and reviewed by the Quality Team quarterly. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on August 24, 2023, the facility failed to maintain each bathroom in a functional manner at all times. Of the two bathrooms in the back of the hallway, the toilet in the bathroom on the left, was not operable when tested one of two times throughout the day.
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. Based on the review of these findings our Director of Facilities ensured that the landlord was called to come and fix the toilet. The toilet has been fixed. To prevent this issue from occurring in the future, the Facility Director will use the Office Checklist to ensure each bathroom has a working toilet. This office checklist will be completed on a monthly basis. The Project Director will monitor and ensure these are completed on a quarterly basis. In addition, any daily issues will be reported to the landlord and/or a plumber will be called by the Facility Director immediately. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from October 2022 through July 2023, the facility failed to ensure that each fire drill log contained the time of the drill and whether the fire alarm or smoke detector was operable. The December 2022 fire drill log did not include the time of the drill. The July 2023 fire drill log did not document whether the fire alarm or smoke detector was operable.
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, the Facility Director was re-trained on the completion of fire drills. The operability of smoke alarm/ fire alarms are completed on a different form. Project Transition will ensure that the form is completed and attached to the fire drill. The Project Director will ensure that all fire drills are completed correctly. |
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.
This is a repeat citation from the September 27, 2022 annual licensing renewal inspection.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The former Director of Finance is no longer with the company. The financial audit for this year has been started by an independent certified accountant and should be completed by 9/30/23. A new Director of Finance has been hired and will ensure that audits are completed in a timely manner. This will be monitored by the Quality team and reviewed with the Finance team on a quarterly basis to ensure completion. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, in one of two applicable personnel records reviewed.
Employee # 2 has been in the clinical supervisor position since March 17, 2022. There was no annual performance evaluation documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The findings were reviewed by the Facility Director, Project Director and the VP of Human Resources. The Facility Directors will monitor and complete annual performance evaluations for all employees on an annual basis. The annual performance review was added to the new supervision and KPI document that is completed on a monthly basis. The Project Director will ensure these documents are completed on a quarterly basis. |
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 # 2 was admitted to the Partial level of care on July 15, 2021 and was discharged on April 14, 2023. The informed and voluntary consent form to the funding source, signed and dated by the client on July 15, 2021, 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.
This is a repeat citation from the September 27, 2022 annual licensing renewal inspection.
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. Within the new Electronic Health Record, the form was re-built with the next one scheduled. This schedule consent will automatically come up on the list of due items for the staff. The Project Director will ensure all consents are fill out completely and correctly for all Members. |
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 a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation, during the preadmission process, in five of six applicable records reviewed.
Client # 1 was admitted on April 27, 2023 and was discharged on July 31, 2023. The record did not contain a psychosocial evaluation.
Client # 5 was admitted on November 8, 2022 and was discharged on December 12, 2022. The record did not contain a psychosocial evaluation.
Client # 6 was admitted on November 17, 2022 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
Client # 7 was admitted on April 4, 2023 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
Client # 8 was admitted on November 23, 2022 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director, Facility Director and the Clinical Supervisor. Upon closer review, Project Transition's new Electronic Health Record had a glitch when we first moved into the new system. It would not save the Biopsychosocial upon completion so some of the earlier assessments are not able to be recovered. The issue has been corrected within the EHR. The Quality Team will add the Biopsychosocial to the admission audit that is completed quarterly. The Executive Clinical Director will ensure all Biopsychosocial Assessments are completed by day of admission. |
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 a review of seven client records and the policies and procedures of the facility, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client on the day of admission, per the facility policy, in two of six applicable records reviewed.
Client # 7 was admitted on April 4, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by April 4, 2023; however, the plan was not completed until May 3, 2023.
Client # 8 was admitted on November 23, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by November 23, 2022; however, the plan was not completed until April 6, 2023.
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 Supervisor. Project Transition has re-trained the clinical team on the importance of having the Treatment Plan completed upon admission. The Quality Department will audit on a weekly basis to ensure all Member has a current Treatment Plan. This information will be reviewed in a weekly meeting with the Facility Director, Project Director and Clinical Supervisor. |
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 document treatment plan updates within the regulatory timeframe in five of six applicable records reviewed.
Client # 1 was admitted on April 27, 2023 and was discharged on July 31, 2023. The individual treatment and the rehabilitation plan was completed on April 27, 2023, and the treatment plan update was due no later than May 27, 2023; however, the update was not completed until July 6, 2023.
Client # 2 was admitted on July 15, 2021 and was discharged on April 14, 2023. A treatment plan update was completed on November 30, 2022, and the next treatment plan update was due no later than December 30, 2022; however, the update was not completed until February 22, 2023. The subsequent treatment plan update was due to be completed by March 22, 2023; however, the record contained no additional treatment plan updates prior to the client's discharge.
Client # 3 was admitted on April 26, 2022 and was discharged on March 17, 2023. A treatment plan update was completed on November 21, 2022, and the next treatment plan update was due to be completed by December 21, 2022; however, the record contained no additional treatment plan updates prior to the client's discharge.
Client # 6 was admitted on November 17, 2022 and was active at the time of the inspection. The treatment and rehabilitation plan was completed on November 17, 2022, and the treatment plan update was due no later than December 17, 2022; however, the next treatment plan update was not completed until April 27, 2023. The subsequent treatment plan update was due to be completed by May 27, 2023; however, the plan was not completed until June 21, 2023.
Client # 7 was admitted on April 4, 2023 and was active at the time of the inspection. A treatment plan update was completed on May 17, 2023, and the next treatment plan update was due to be completed by June 17, 2023; however, the next plan was not documented until July 18, 2023.
Client # 8 was admitted on November 23, 2022 and was active at the time of the inspection. A treatment plan update was completed on June 22, 2023, and the next treatment plan update was due no later than July 22, 2023; however, the update was not completed until August 7, 2023.
This is a repeat citation from the September 27, 2022 annual licensing renewal inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
These findings were reviewed with the Project Director, the Facility Director and the Clinical Supervisor. Project Transition has re-trained the clinical team on the importance of having the Treatment Plan completed every 30 days. The Quality Department will audit on a weekly basis to ensure all Member has a current Treatment Plan. This information will be reviewed in a weekly meeting with the Facility Director, Project Director and Clinical Supervisor. |
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 ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every 60 days, per the facility's policy, in six of seven applicable records reviewed.
Client # 1 was admitted on April 27, 2023 and was discharged on July 31, 2023. The record contained no documentation of case consultation notes.
Client # 2 was admitted on July 15, 2021 and was discharged on April 14, 2023. A case consultation was documented on September 9, 2022, and the next consultation was due to be completed by November 9, 2022; however, no subsequent treatment plan updates were completed prior to the client ' s discharge.
Client # 3 was admitted on April 26, 2022 and was discharged on March 17, 2023. A case consultation was documented on September 30, 2022, and the next consultation was due to be completed by November 30, 2022; however, no subsequent treatment plan updates were completed prior to the client ' s discharge.
Client # 4 was admitted on October 19, 2022 and was discharged on January 20, 2023. The record contained no documentation of case consultation notes.
Client # 7 was admitted on April 4, 2023 and was active at the time of the inspection. A case consultation was documented on May 26, 2023, and the next consultation was due to be completed by July 26, 2023; however, no subsequent treatment plan updates were completed prior to the date of the inspection.
Client # 8 was admitted on November 23, 2022 and was active at the time of the inspection. The first case consultation was due to be completed by January 23, 2023; however, it was not documented until March 3, 2023. The next consultation was due to be completed by May 3, 2023; however, the next case consultation did not occur until June 9, 2023.
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, Facility Director and Clinical Supervisor. Project Transition will add the Big Team (Case Consult) to the weekly auditing tool that is reviewed with the Project Director, Facility Director and Clinical Supervisor. The Project Director will ensure that these are completed every 60 days. |
709.83(a)(6) 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in one of two applicable records reviewed.
Client # 3 was admitted on April 26, 2022 and was discharged on March 17, 2023. The client record did not contain documentation of a completed aftercare plan.
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 an the Facility Director. Based on the review of these findings, to prevent this issue from occurring in the future, Project Transition is adding the completion of the After Care Plan (APPLE - Plan) to the Social Worker's KPI Supervision Document. The APPLE Plan has also added to the audit document that is reviewed on a weekly basis with the Facility Director and Project Director. The Project Director will ensure that each Member who leave the program has a completed After Care Plan. |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project including a discharge summary, in five of five applicable records reviewed.
Client # 1 was admitted on April 27, 2023 and was discharged on July 31, 2023. The client record did not contain documentation of a completed discharge summary.
Client # 2 was admitted on July 15, 2021 and was discharged on April 14, 2023. The client record did not contain documentation of a completed discharge summary.
Client # 3 was admitted on April 26, 2022 and was discharged on March 17, 2023. The client record did not contain documentation of a completed discharge summary.
Client # 4 was admitted on October 19, 2022 and was discharged on January 20, 2023. The client record did not contain documentation of a completed discharge summary.
Client # 5 was admitted on November 8, 2022 and was discharged on December 12, 2022. The client record did not contain documentation of a completed discharge summary.
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 an the Facility Director. Based on the review of these findings, to prevent this issue from occurring in the future, Project Transition is adding the completion of the Discharge Summary (APPLE - Leave) to the Social Worker's KPI Supervision Document. The APPLE Plan (including the discharge summary) has also added to the audit document that is reviewed on a weekly basis with the Facility Director and Project Director. The Project Director will ensure that each Member who leave the program has a completed the Discharge Plan. |
709.83(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including monthly follow-up information, per the facility's policy and procedures, in four of four applicable records reviewed.
Client # 2 was admitted on July 15, 2021 and was discharged on April 14, 2023. The client record did not contain documentation of monthly follow-up information.
Client # 3 was admitted on April 26, 2022 and was discharged on March 17, 2023. The client record did not contain documentation of monthly follow-up information.
Client # 4 was admitted on October 19, 2022 and was discharged on January 20, 2023. The client record did not contain documentation of monthly follow-up information.
Client # 5 was admitted on November 8, 2022 and was discharged on December 12, 2022. The client record did not contain documentation of monthly follow-up information.
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 the Facility Director. To prevent this issue from occurring in the future, Project Transition added Discharge Follow Up to the KPIs, which will be monitored a minimum of monthly by the Facility Director. The Regional Operations Director will ensure that follow up documentation is being completed. |