INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14, 2021 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, 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 (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 review of the facility's August 2020 through August 2021 fire drill logs, the facility failed to conduct an unannounced fire drill during the month of November 2020.
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 and Facility Director. Project Transition's physical location was not open during the months of March 2020 through March 2021 due to the COVID-19 pandemic. Project Transition has since opened the office back up and has resumed conducting monthly fire drills. In the future, if an exception is needed, the Quality Department will file an exception with the Department of Drug and Alcohol. 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. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to assure that a copy of a client consent was offered to the client and a copy maintained in the client record in three of seven client records reviewed.
Client #1 was admitted on January 4, 2021 and was active at the time of inspection. Release of information forms to a pharmacy, a funding source and an emergency contact were all signed and dated by the client on January 4, 2021 and there was no documentation for any of the forms that indicated a copy was offered to the client.
Client #2 was admitted on July 1, 2021 and was active at the time of inspection. Release of information forms to a funding source, a pharmacy and an emergency contact were all signed and dated by the client on July 1, 2021 and there was no documentation for any of the forms that indicated a copy was offered to the client.
Client #3 was admitted on November 10, 2020 and was active at the time of inspection. Release of information forms to a hospital and a primary care physician were signed and dated by the client on November 10, 2020 and there was no documentation for either form that indicated a copy was offered to the client.
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. Based on the review of these findings, all current Member's consents were updated with the updated version of the consent that includes asking the Member if they have been offered a copy. Project Transition has re-designed the consent. The consent was updated and now includes a place where the Member can check if they have been offered a copy. The Facility Director will ensure consents are completed for all Members.
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