INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to ensure all heaters units were permanently mounted or installed. Based on the physical plant inspection conducted at approximately 3:00 pm, a space heater was found in counseling office #1.
The findings were discussed with facility staff during the licensing process
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Plan of Correction
These findings were reviewed with the Project Director and Facitlity Director. Based on the review of these findings, Project Transition removed the portable heater in question. Project Transition will re-train and re-implement the Safety Checklist that is completed on a monthly basis. This Safety Checklist has staff look at many safety items including that there are no portable heaters or coolers in the office. This re-training will occur on 9/25/19. Project Transition will also have maintenance look at the temperature of air flow to ensure that temperatures are within a normal comfortable range for staff and members. The Safety Checklist will be completed monthly by the Facility Director. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in 1 of 7 client records.
Client #4 was admitted into the partial hospitalization activity on February 13, 2019 and was discharged May 12, 2019. The facility's policy and procedure manual stated that the initial treatment plan must be developed within 24 hours from admission; however, the initial treatment plan was not completed until June 20, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The 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 Vice President of Clinical Services will conduct a re-training on the Treatment Planning process to ensure that initial Treatment Plans are reviewed and signed upon admission. This re-training will occur 9/26/19. The Vice President of Clinical Services will ensure that Treatment Plans are timely and will use progressive discipline if trends of non-compliance is found with individual clinicians. |
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.
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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 for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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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 2019. Project Transition will continue to have an independent financial audit yearly. Project Transition has hired a new Director of Finance and has also purchased and implemented new systems which should improve timeliness of our annual audit. The Director of Finance will ensure that the financial audit is completed within 6 months of the following year.
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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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in five of seven client records reviewed.
Client #1 was admitted into the partial hospitalization activity January 22, 2019 and was active at the time of inspection. Consent to release information forms to the funding source, signed and dated by the client, allowed for the release of all progress notes, assessments, care plans, drug and alcohol history which exceeded 255.5.
Client #2 was admitted into the partial hospitalization activity on February 17, 2019 and was active at the time of inspection. Consent to release information forms to the funding source, signed and dated by the client, allowed for the release of all progress notes, assessments, care plans, drug and alcohol history which exceeded 255.5.
Client #3 was admitted into the partial hospitalization activity on March 24, 2019 and was active at the time of inspection. Consent to release information forms to the funding source, signed and dated by the client, allowed for the release of all progress notes, assessments, care plans, drug and alcohol history which exceeded 255.5.
Client #4 was admitted into the partial hospitalization activity on February 13, 2019 and was discharged May 12, 2019. Consent to release information forms to the funding source, signed and dated by the client, allowed for the release of all progress notes, assessments, care plans, drug and alcohol history which exceeded 255.5.
Client #7 was admitted into the partial hospitalization activity on February 27, 2019 and was discharged July 31, 2019. Consent to release information forms to the funding source, signed and dated by the client, allowed for the release of all progress notes, assessments, care plans, drug and alcohol history which exceeded 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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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 10/15/19 and will include disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b). The Facility Director will ensure consents are completed for all Members. |