INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on February 4, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on consent to release information forms in five of seven client records reviewed.
Client # 1 was admitted on January 21, 2020 and was still active at the time of inspection. Release of information forms to a funding source, a government agency, a housing provider, an outside individual, and a pharmaceutical service were signed and dated by the client on January 21, 2020; however, all of the release of information forms did not document the purpose of disclosure.
Client # 4 was admitted on September 25, 2019 and was discharged on August 5, 2020. Release of information forms to a funding source, a government agency, a housing provider, an outside individual, and a pharmaceutical service were signed and dated by the client on September 25, 2019; however, all of the release of information forms did not document the purpose of disclosure.
Client # 5 was admitted on December 17, 2019 and was discharged on August 11, 2020. Release of information forms to a funding source, a government agency, a housing provider, and a pharmaceutical service were signed and dated by the client on December 17, 2019; however, all of the release of information forms did not document the purpose of disclosure.
Client # 6 was admitted on January 8, 2020 and was discharged on July 28, 2020. Release of information forms to a funding source, a government agency, a housing provider, an outside individual, a service access management company, and a pharmaceutical service were signed and dated by the client on January 8, 2020; however, all of the release of information forms did not document the purpose of disclosure.
Client # 7 was admitted on January 13, 2020 and was discharged on August 28, 2020. Release of information forms to a funding source, a government agency, a housing provider, an outside individual, and a pharmaceutical service were signed and dated by the client on January 13, 2020; however, all of the release of information forms did not document the purpose of disclosure.
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, Project Transition will need to re-design the consent. The consent will be updated by 3/15/21 and will include purpose of disclosure. The Director of Outcomes and Systems Development will ensure the consent is updated in the EHR. The Facility Director will ensure consents are completed for all Members. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a dated signature of the client on release of information forms in two of seven client records.
Client # 3 was admitted on February 26, 2020 and was still active at the time of inspection. There was a release of information form to a primary care physician that was signed and dated by staff on April 1, 2020; however, the dated signature of the client was not documented.
Client # 4 was admitted on September 25, 2019 and discharged on August 5, 2020 There was a release of information form to a primary care physician that was signed and dated by staff on March 31, 2020; however, the dated signature of the client was not documented.
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, it was determined that some of the deficiencies were created by staff when the Member was unable to sign In these cases, staff never went back and obtained the Member's signature. Any consents that have been created without the Member's signature will be de-activated and new consents will be created and signed by both the staff and Member by 2/15/21. To prevent this issue from occurring in the future, Project Transition is implementing a Quality Review at the program level, which will include monitoring consents for all Members. This will be monitored by the Facility Director. |
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 document that a copy of a client consent form was offered to the client in seven of seven client records.
Client # 1 was admitted on January 21, 2020 and was still active at the time of inspection. Release of information forms to a funding source, a government agency, a housing provider, and a pharmaceutical service were signed and dated by the client on January 21, 2020; however, all of the release of information forms did not document that a copy was offered to the client.
Client # 2 was admitted on February 24, 2020 and was still active at the time of inspection. Release of information forms to a funding source, a government agency, a housing provider, an outside individual, and a pharmaceutical service were signed and dated by the client on February 24, 2020; however, all of the release of information forms did not document that a copy was offered to the client.
Client # 3 was admitted on February 26, 2020 and was still active at the time of inspection. Release of information forms to a funding source, a government agency, a housing provider, an outside individual and a pharmaceutical service were signed and dated by the client on February 26, 2020; however, all of the release of information forms did not document that a copy was offered to the client.
Client # 4 was admitted on September 25, 2019 and was discharged on August 5, 2020. Release of information forms to a funding source, a government agency, a housing provider, an outside individual, and a pharmaceutical service were signed and dated by the client on September 25, 2019; however, all of the release of information forms did not document that a copy was offered to the client.
Client # 5 was admitted on December 17, 2019 and was discharged on August 11, 2020. Release of information forms to a funding source, a government agency, a housing provider, and a pharmaceutical service were signed and dated by the client on December 17, 2019; however, all of the release of information form did not document that a copy was offered to the client.
Client # 6 was admitted on January 8, 2020 and was discharged on July 28, 2020. Release of information forms to a funding source, a government agency, a housing provider, an outside individual, and a service access management company were signed and dated by the client on January 8, 2020; however, all of the release of information forms did not document that a copy was offered to the client.
Client # 7 was admitted on January 13, 2020 and was discharged on August 28, 2020. Release of information forms to a funding source, a government agency, a housing provider, an outside individual, and a pharmaceutical service were signed and dated by the client on January 13, 2020; however, all of the release of information forms did not document that 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, Project Transition will need to re-design the consent. The consent will be updated by 3/15/21 and will include a place where the Member can check if they have been offered a copy. The Director of Outcomes and Systems Development will ensure the consent is updated in the EHR. The Facility Director will ensure consents are completed for all Members. |
709.82(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to properly document the type and frequency of treatment and rehabilitation services in the client's comprehensive treatment plan in six of seven client records reviewed.
Client # 1 was admitted on January 21, 2020 and was still active at the time of inspection. The comprehensive treatment plan was completed on January 21, 2020; however, the plan did not include type and frequency of treatment and rehabilitation services.
Client # 2 was admitted on February 24, 2020 and was still active at the time of inspection. The comprehensive treatment plan was completed on February 24, 2020; however, the plan did not include type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on February 26, 2020 and was still active at the time of inspection. The comprehensive treatment plan was completed on February 26, 2020; however, the plan did not include type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on September 25, 2019 and was discharged on August 5, 2020. The comprehensive treatment plan was completed on September 26, 2019; however, the plan did not include type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on December 17, 2019 and was discharged on August 11, 2020. The comprehensive treatment plan was completed on December 17, 2019; however, the plan did not include type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on January 13, 2020 and was discharged on August 28, 2020. The comprehensive treatment plan was completed on January 13, 2020; however, the plan did not include type and frequency of treatment and rehabilitation services.
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, the Facility Director and the Clinical Director. Based on the review of these findings, the process for when Treatment Plans are signed will be updated. During the weekly Treatment Team meeting, all signing parties will need to sign at the time of review. A report will be run prior to the meeting by the Facility Director to notify staff which plans need to be reviewed and signed. This will begin 4/1/21. This will be monitored by he VP of Clinical Services. |