INITIAL COMMENTS
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This report is a result of an unannounced inspection conducted on February 23, 2012 by staff from the Division of Drug and Alcohol 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a review of the physical plant, the facility failed to ensure that counseling sessions could not be seen or heard from outside the counseling area. The findings included: An unannounced inspection was conducted on 2/22/2012. Division staff entered the building during the course of a morning treatment group. The large group area used for such meetings is located about 15 feet from the entrance to the office suite behind a receptionist desk and adjacent to the waiting area. Division staff was able to see and hear everything going on in the group room upon entering the suite. The door to the group room was left open during the meeting and there was an overflow of clients standing in the waiting area participating in the meeting. There was no privacy noted during this meeting. The findings were reviewed with the Facility Director and an administrative staff present and were not disputed.
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Plan of Correction
Project Transition Andorra Program will keep the door to the group room closed during any groups or meetings. The Program Secretary of the Project Transition Andorra Program will ensure that this is happening. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observations made during the physical plan inspection, the facility failed to ensure that there were no portable space heaters in use. The findings included: An unannounced inspection was conducted on 2/22/12 by Division staff. A portable space heater was observed in the computer area during the physical plant inspection. Staff use this area to complete required paperwork. The findings were reviewed with facility staff and were not disputed..
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Plan of Correction
4. Project Transition Andorra Program Director will remove any space heater in the program. The Program Director will on a weekly basis conduct an inspection to verify that staff are not using space heaters |
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 fire drill documentation, the facility failed to document fire drills monthly from the date they were initially licensed. The findings included: An unannounced plan of correction follow up inspection was conducted on February 22, 2012. Division staff asked to see documentation of fire drills from August 10, 2011 to January 31, 2012. There was no documentation of fire drills from the time the facility was authorized to begin providing drug and alcohol treatment services through to January 31, 2012.The findings were reviewed with the facility staff and they indicated that they did not actually begin providing D&A services until January 2012 and did not think they needed to conduct fire drills. No additional documentation was provided to demonstrate that the required drills had been conducted.
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Plan of Correction
Project Transition Andorra Program director will ensure that fire drills are conducted on a monthly basis. The Quality Improvement team will review fire drills on a monthly basis to ensure that they are occurring. |
709.83(a)(8) 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:
(8) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document records of service in three of three client records reviewed.The findings include:A plan of correction follow up inspection was conducted on 2/22/2012. Three client records were reviewed. Three of three client records reviewed failed to include documentation of a record of service.Client record # 1 - This client was admitted to the mental health component of the program on 10/18/2010. Based on the available documentation, the client began receiving Drug and Alcohol partial hospitalization treatment services on 5/18/11 at another Project Transition location, which continued at this location. There was no documentation in the client record of a record of services provided.Client record # 2- This client was admitted on 9/16/10 and was identified by the facility director and a counselor as a Drug and Alcohol treatment client. The client record did not include documentation of drug and alcohol related treatment goals. It was not possible, based on client record documentation, to determine exactly when the client began receiving drug and alcohol related treatment services, but the earliest certain date was January 4, 2012. There was no documentation of a record of services in the client record from January 4, 2012 to February 22, 2012.Client record # 3- The client was admitted to the mental health treatment program on 9/24/10. The earliest date demonstrating the provision of drug and alcohol treatment services was 2/24/11. There was no documentation of a record of service in the client record. The findings were reviewed with the facility director and administrative staff on site and were not disputed. The facility director acknowledged that there were no records of services placed in any of the records to date.
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Plan of Correction
Counselors of Project Transition Andorra will place completed logs of service in each members chart receiving D & A services weekly even if the member is receiving services at another location. The Quality Improvement Department will audit each members chart on a monthly basis for D & A logs of service |
709.28(c)(2) 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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to ensure that disclosures of client identifying information the criminal justice entities, government officials and third party payers did not exceed the limitations imposed by Commonwealth regulation at 4 Pa. Code subsection 255.5(b). The findings included:Three client records were reviewed during the unannounced onsite licensing inspection conducted on 2/23/2012. Two of three client records included documentation of disclosures of information to an insurance companies which exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).Client record #1 - The client was admitted to the mental health component of the program on 10/18/2010 and began receiving Drug and Alcohol treatment services on 5/18/11 at another Project Transitions location before the transfer to this site. Documented disclosures of information to the insurance company exceeded the limits imposed by 4 Pa. Code Subsection 255.5 (b) by releasing information on the specifics of the medications taken by this client including the drug, dosage and frequency of use. The information released also included information about the client's proficiency in daily living skills, school adjustment, leisure activities and medication management issues. One counselor was interviewed at approximately 12:00 P.M. and verified that this information was forwarded to the managed care provider. The releases of information to the third party payers occurred from 7/15/11 to 9/12/11; 9/13/11 to 11/11/11; 11/12/11 to 1/10/12; and 1/11/12 to 3/10/12.Client record #2- This client was admitted to the mental health treatment program on 9/16/10. The client began receiving drug and alcohol treatment services on 1/4/12 based on documentation in group and individual treatment notes. Documented disclosures of information to the insurance company exceeded the limitations imposed by 4 Pa. Code subsection 255.5 (b) by naming the medications taken by the client including the drug, the dosage and the frequency of use. The facility also released information regarding the client's proficiency in daily living skills, school adjustment, leisure activities and medication management issues. One counselor was interviewed at approximately 12:00 P.M. and verified that this information was forwarded to the managed care provider. The releases of information to the third party payers occurred from 1/9/12 to 3/8/12. The facility also released information to the managed care provider regarding the client's employment and medical referrals made on behalf of the client. The findings were reviewed with the facility director and administrative staff on site and were not disputed.
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Plan of Correction
Project Transition will revise its procedure for releasing information to insurance company that does not exceed limitations imposed limitations at the 4 pa. code subsection 255.5 (b). The Program Director will monitor reviews with insurance companies to verify that information disclosed does not exceed the limitations. |