INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 8, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of five personnel records, it was determined that the facility failed to ensure that each counselor met the experiential portion of the qualifications for the position of counselor in one record.
Employee # 5 was hired as a counselor on 12/19/16 and was in that position at the time of inspection. At the time of the inspection, the employee had a qualifying Bachelor's degree; however, there was only 9 months of documented clinical experience.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
These findings were reviewed with the Project Director, Facility Director and the Human Resources and Training Manager. Based on the review of these findings, the employee in question was moved to a counselor assistant. To prevent this issue from from occurring in the future, the Human Resources and Training Manager will ensure that when hiring a new employee for the position of counselor, they have all qualifications in the regulation. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of five personnel records, one record contained documentation of fire extinguisher that was not completed upon employment. Employee # 5 was hired on 12/19/16 but did not complete fire safety training until 4/8/17.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
These findings were reviewed with the Project Director, Facility Director and the Human Resources and Training Manager. Based on the review of these findings, Project Transition's Fire Safety Training will be added to the orientation packet that is completed upon employment. The Human Resources and Training Manager will ensure that they receive a completed Fire Safety Training signed by the employee and the Facility Director upon employment at the facility. |
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.
|
Observations
Based on a review of administrative documentation during the licensing process, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
These findings were reviewed with the Director of Finance and the CEO. Project Transition is currently engaged with an outside accounting firm who has conducted an independent financial audit. The results of this audit have been completed as of 9/27/17. Project Transition will continue to have an independent financial audit yearly. The Director of Finance will ensure that the audit will be started earlier to ensure that it has been completed within 6 months of the following year. |
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.
|
Observations
Based on a review of five personnel records, the facility failed to ensure that personnel records contained documentation of an employee-signed, annual written individual performance evaluation in two employee records.
Employee # 3 had been employed since 8/10/11 and as a clinical supervisor since 2015. The annual employee evaluation, dated 3/15/17, was not signed by the employee.
Employee #4 has been employed as a counselor since 4/8/16. The record contained no documentation of an annual employee evaluation at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
These findings were reviewed with the Project Director, the Facility Director and the Human Resources and Training Manager. Based on the review of these findings, the Human Resources and Training Manager has reviewed all employee records and confirmed which employees have not had an annual performance evaluation. All employees without annual performance evaluations will have them completed by 10/15/17. To prevent this issue from occurring in the future, the Human Resources and Training Manager will ensure that the annual performance evaluations are entered into Project Transition's Relias E-Learning system. The Facility Director and employee will receive notification within 30 days of the annual performance evaluation being due. This will be monitored and tracked by the Human Resources and Training Manager. |
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.
|
Observations
Based on a review of seven client records, the facility disclosed information without a client signed informed and voluntary consent to release form in four records. Additionally, a consent to release information form in one client record was missing required elements.
Client #1 was admitted on 3/10/16 and was discharged 7/7/17. The record did not contain a current consent to release information form to the funding source; however, there was evidence of the release of information.
Client #2 was admitted on 3/29/16 and was discharged 5/31/17. The record did not contain a current consent to release information form to the funding source; however, there was evidence of the release of information.
Client #4 was admitted on 5/12/16 and was discharged on 7/25/17. The record contained results for laboratory analysis dated 12/21/16, which indicated that the client's presence in treatment was disclosed through the submission process, without a consent to release information form or Qualified Service Organization Agreement in place. Additionally, the record contained documentation of a session with another treatment provider on 4/26/17, for whom there was no client signed consent to release information form.
Client #5 was admitted on 10/21/16 and was an active client at the time of the inspection. The record contained a consent to release information form to another service provider, which was not signed or dated by the client or witness.
Client #6 was admitted on 1/11/17 and was an active client at the time of the inspection. The record contained results for laboratory analysis dated 5/17/17, which indicated that the client's presence in treatment was disclosed through the submission process, without a consent to release information form or Qualified Service Organization Agreement in place.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
These findings were reviewed with the Project Director and the Facility Director. Based on the review of these findings, the Quality and Outcomes Manager has audited all member consents. New consents are to be completed for any consents that are expired or have any other deficiencies by 10/15/17. To prevent this issue from occurring in the future, the Quality and Outcomes Manager will conduct a re-training that covers the importance of obtaining consent as well as the proper way to fill out the consent forms will occur with staff on 10/11/17 and 10/12/17. This will be monitored and tracked by the Project Director. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
|
Observations
During the inspection on September 8, 2017, it was discovered that the facility had one client death while he/she was an active patient since the previous licensing inspection. The facility was notified of the death on October 2, 2017. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory timeframe.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
These findings were reviewed with the Project Director and the Facility Director. Based on the review of these findings, the incident in question was reported to the Department on 10/6/17. Project Transition's Incident Management Process will be updated to include the notification of death, serious injury due to trauma, suicide, medication error or unusual circumstances regardless of where the incident occurred. Project Transition's Quality and Outcomes Manager will file a written unusual incident report with the Department within 3 business days following an unusual incident. This will be monitored and tracked by the Quality and Outcomes Manager. |
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.
|
Observations
Based on a review of seven client records, six records had treatment plan updates completed after the regulatory timeframe.
Client #1 was admitted on 3/10/16 and was discharged on 7/7/17. The comprehensive treatment and rehabilitation plan was completed on 10/8/16 and a treatment plan update was not completed until 12/6/16. Additionally, a treatment plan update was due by 2/18/17, but was not completed until 3/1/17.
Client #2 was admitted on 3/29/16 and was discharged on 5/31/17. Treatment plan updates for 10/28/16 and 1/30/17 were completed on 1/30/17. The record contained no treatment plan updates for the months of November 2016, December 2016, and February 2017.
Client #3 was admitted on 6/2/16 and was discharged on 10/3/16. A treatment plan update was completed on 7/25/16 and the next update was due by 8/25/16. However, no additional updates were completed prior to the client's discharge.
Client #4 was admitted on 5/12/16 and was discharged on 7/25/17. Treatment plan updates for 8/31/16 and 9/12/16 were not completed until 10/6/16. No treatment plan updates were completed in the month of November 2016. Treatment plan updates for 12/7/16 and 12/28/16 were not completed until 1/6/17. A treatment plan update was due by 2/25/17 but was not completed until 3/27/17. There was no treatment plan update completed in April 2017, and the treatment plan update for 5/11/17 was not completed until 7/6/17.
Client #5 was admitted on 10/21/16 and was an active client at the time of the inspection. The treatment plan updates for 12/23/16 and 4/17/17 were not completed until 1/25/17 and 5/18/17, respectively.
Client #6 was admitted on 1/11/17 and was an active client at the time of the inspection. The comprehensive treatment and rehabilitation plan was completed on 1/26/17. The treatment plan updates for 3/2/17 and 3/22/17 were not completed until 5/6/17 and 4/13/17, respectively.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
These findings were reviewed with the Project Director, the Facility Director and the Vice President of Clinical Services. Based on the review of these findings, the Clinicians will take over the completion of the Treatment Plan under the supervision of the Vice President of Clinical Services. To prevent this issue from occurring in the future, the Facility Director will ensure that the completion of all Treatment Plans will be audited on a weekly basis. This will be monitored and tracked by the Project Director. |
709.83(a) 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:
|
Observations
Based on a review of seven client records, the facility failed to provide a complete client record in three records.
Client #1 was admitted on 3/10/16 and discharged on 7/17/17. The client record did not contain any documentation of follow-up information as of the date of the inspection.
Client #2 was admitted on 3/29/16 and was discharged on 5/31/17. The client record did not contain any documentation of follow-up information as of the date of the inspection.
Client #3 was admitted on 6/2/16 and was discharged on 10/3/16. The client record did not contain any documentation of a discharge summary as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
These findings were reviewed with the Project Director and the Facility Director. Based on the review of these findings, follow up contact was attempted with clients #1 and #2 on 10/6/17. A discharge summary was also completed for client #3 on 10/6/17. Staff will be retrained on Project Transition's Graduation/Discharge Follow Up Protocols, which include reaching out to the member for a year post Graduation/Discharge. The Project Director will ensure that post Graduation/Discharge contact is occurring. |