INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 19, 2018 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
|
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
The facility failed to demonstrate sufficient coverage of staff certified in CPR and First Aid during the 8:00 A.M. to 4:00 P.M. shift on August 12, 2018 and August 26, 2018. Additionally, the facility failed to demonstrate sufficient coverage of staff certified in CPR and First Aid during the 4:00 P.M. through 9:00 P.M. shift on August 25, 2018. Lastly, the facility failed to demonstrate sufficient coverage of staff certified in CPR and First Aid for all shifts on the following dates:
July 29, 2018
August 5, 2018
August 19, 2018
The 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 a current CPR/First Aid Certification. The Human Resources and Training Manager will ensure that a copy of all employee's CPR/First Aid Certification is placed in their chart by 9/30/18. The Human Resources and Training Manager has informed the Facility Director, who will ensure that each scheduled shift has at least one staff person with a current CPR/First Aid Certification. To prevent this issue from occurring in the future, the Human Resources and Training Manager will provide CPR/First Aid Certification during orientation. |
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.
|
Observations
The facility failed to ensure that all heaters in the facility were permanently mounted or installed as there was a space heater found in the psychiatrist's office and a space heater found in the storage room.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
These findings were reviewed with the Project DIrector and the Facility Director. Based on the review of these findings, confirmation that there are no space heaters in the facility was added to the Monthly Safety Checklist completed by the Director of Facilities. The Project Director will ensure that the Monthly Safety Checklist is completed at each facility and that there are no space heaters in use or in storage 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
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. The Facility Director confirmed that no annual financial audit was conducted for the 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 is currently conducting an independent financial audit. The results of this audit will be completed by October 2018. 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
The facility failed to ensure that personnel records contained documentation of an annual written individual performance evaluation in two employee records reviewed.
Employee # 1 was hired as the Project Director on September 1, 2014. There was no documentation of an annual written individual performance evaluation completed for the review year.
Employee # 3 was hired as a Clinical Supervisor on June 23, 2017. There was no documentation of an annual written individual performance evaluation completed for the review year.
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 10/15/18. 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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed. Additionally, the facility failed to document dated client and witness signatures in two of seven client records reviewed.
Client #1 was admitted to the partial hospitalization level of care on May 4, 2018. There was documentation of correspondence with a hospital on August 3, 2018; however, there was no active consent to release information form on file prior to the disclosure of information.
Client #3 was admitted to the partial hospitalization level of care on December 2, 2008 and was discharged on July 14, 2018. There was a consent to release information form to a nursing home; however, the form did not include the dated client and witness signatures.
Client #4 was admitted to the partial hospitalization level of care on June 22, 2017 and was discharged on March 16, 2018. There was documentation of the facility billing the funding source; however, there was no active consent to release information form on file prior to the disclosure of information. Additionally, there was documentation of correspondence with a probation officer on October 16, 2017 and a family member on December 15, 2017; however, there were no active consent to release information forms on file prior to the disclosures of information.
The findings were reviewed with facility staff during the licensing inspection.
|
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 duplicate consents entered. Some of these duplicates did not have signatures on them. Any duplicate consents without signatures will be closed out and new consents are to be completed by 10/15/18. To prevent this issue from occurring in the future, Project Transition is implementing a new EHR system. Within this system, consents will be tracked and updated when necessary. This will be monitored and tracked by the Project Director. |
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
The facility failed to provide treatment plan updates within the regulatory timeframe in six of seven client records reviewed.
Client #2 was admitted on November 13, 2017 and was active at the time of inspection. A comprehensive treatment and rehabilitative plan was completed on November 3, 2017 and an update was due no later than December 13, 2017. However, the update was not completed until January 16, 2018.
Client #3 was admitted on December 2, 2008 and was discharged on July 14, 2018. A treatment plan update was completed on August 24, 2017 and the next update was due no later than September 24, 2017. However, the update was not completed until November 22, 2017. Additionally, there was no treatment plan update completed for the month of December 2017.
Client #4 was admitted on June 22, 2017 and was discharged on March 16, 2018. A treatment plan update was completed on August 24, 2017 and the next update was due no later than September 24, 2017. However, the update was not completed until January 4, 2018.
Client #5 was admitted on October 13, 2017 and was an active client at the time of the inspection. A treatment plan was completed on December 20, 2017 and the next update was due no later than January 20, 2018. Additionally, there were no treatment plan updates completed for the months of April 2018 and August 2018.
Client #6 was admitted on July 25, 2018 and was an active client at the time of the inspection. A treatment plan update was completed on August 3, 2018 and the next update was due no later than September 3, 2018. However, the update was not completed at the time of the inspection.
Client #7 was admitted on October 30, 2017 and was discharged on November 10, 2017. The comprehensive treatment plan was completed on August 24, 2017 and the first update was due no later than September 24, 2017. However, the update was not completed prior to discharge.
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, Project Transition is implementing a new Electronic Medical Record (EHR). The new EHR will allow Treatment Plans to be tracked and signed more easily. The Project Director will ensure that all Treatment Plans are completed in a timely manner. |