INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 16-18, 2018 by staff from the Division of Drug and Alcohol Program Licensure, for the approval to use Methadone in the treatment of narcotic addiction. Based on the findings of the on-site inspection, Soar Corp. 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
|
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
|
Observations
Staffing Requirements Facility Summary Reports for all facilities of the project were reviewed for the licensing renewal inspection conducted at this specific facility on January 16-18, 2018. Based on this review, the project failed to employ one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors or counselor assistants employed with the project.
The Staffing Requirements Facility Summary Reports submitted for the three facilities within the project identify three employees in the clinical supervisor position. The total number of hours per week provided to the project, by the counselors and counselor assistants, equates to 32 FTE counselor or counselor assistant positions within the project.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
An additional clinical supervisor was hired and started working for Soar Corp on 1/10/18 at the Northeast Site to replace the previous clinical supervisor that was on medical leave. Qualifications were reviewed on site for this individual. The Regional Project Director and Human Resource Director shall continue to ensure the 8 to 1 ratios for supervisors are maintained to ensure compliance with the regulation |
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
Personnel records were reviewed on January 16, 2018. The facility failed to ensure that each counselor met the qualifications for the position at the time of hire for employee records # 18 and 19.
Employee # 18 was hired as a counselor on 9/12/17. The qualifications documented in the employee's record indicated that the employee completed a Bachelor's degree in Psychology. Documentation of the employee's prior work experience failed to demonstrate that the employee acquired at least 1 year of prior clinical experience (a minimum of 1,820 hours). Therefore, the employee did not meet the qualifications for the counselor position.
Employee # 19 was hired as a counselor on 3/27/17. The qualifications documented in the employee's record indicated that at the time of hire, the highest level of education completed by the employee was a Bachelor's degree in Psychology. Documentation of the employee's prior work history failed to demonstrate that the employee acquired at least 1 year of prior clinical experience (a minimum of 1,820 hours). The employee has since acquired a Master's degree in Counseling Psychology, completed in May 2017.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
As of 3/22/18, Employee 18 will sign a job description of assistant counselor and will be required to complete a additional documented 6 months of close supervision involving direct observation and weekly supervision. As of 3/22/18, Employee 19 will sign a job description of a assistant counselor and will be required to complete a additional documented 3 months of close supervision involving direct observation and weekly supervision. The clinical supervisor assigned to the counselor shall keep proof of the documented supervisor and close observation within the supervision binder. Effective Immediately, Upon hire, the Human Resource Director shall review the potential employee's qualifications for the position at the time of hire to ensure qualifications are met. After the Human Resource Director has reviewed the information, a secondary review the potential employee's qualifications for the position shall be completed by the regional project director to ensure qualifications are met. This 2 step verification process is now in effect as of this date and will be ongoing. Proof of the verification process will be indicated on the employee job description by the signature of the regional Project Director and H.R. |
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.
|
Observations
A physical plant inspection was conducted on January 18, 2018. Two unmounted space heaters were observed in the main security entrance of the facility. One space heaters was in use at the time of the physical inspection.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Effective Immediately the two space heaters being referenced have been removed by the Regional Project Director. The Security Firm hired by Soar Corp has been notified to reinforce the policy on space heaters. Currently there are no space heaters being used within the facility. To ensure compliance with the directive, both the Regional Project Directors and the Clinical Supervisors of the program shall enforce the standard. |
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
Administrative records were reviewed for documentation of an annual fiscal audit during the facility's licensing renewal inspection, conducted on January 16-18, 2018. The facility's fiscal year runs from October 1 to September 30. The document presented as the project's annual financial audit, for the fiscal year ending on September 30, 2016, was titled "Financial Statements." However, this document did not contain the opinion of the accountant, and included a statement indicating that an audit was not conducted.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Soar Corp's CEO will request that the Board of Directors approve a authorization for a audit to be completed for the Oct 1, 2016 to Sept 30th 2017 time period. The request for the audit shall be made at the next board meeting in 60 days. The CEO will be responsible in facilitating and arranging for a independent auditor within the next 90 days. Proof of completion shall be supplied as needed to the regional project director to meet the standard. Ongoing the CEO will make request for the approval of a auditor annually in the first quarter of each year |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Physician time sheets and weekly census reports for the months of September - December 2017 were reviewed for the licensing renewal inspection, conducted on January 16-18, 2018. The facility provided insufficient onsite physician hours for five weeks within the reviewed time period.
For the week of September 10, 2017, the reported patient census was 551. The facility was required to provide at least 55.1 onsite physician hours. There were 54 onsite physician hours documented for this week.
For the week of September 17, 2017, the reported patient census was 558. The facility was required to provide at least 55.8 onsite physician hours. There were 54 onsite physician hours documented for this week.
For the week of October 1, 2017, the reported patient census was 554. The facility was required to provide at least 55.4 onsite physician hours. There were 54 onsite physician hours documented for this week.
For the week of October 8, 2017, the reported patient census was 557. The facility was required to provide at least 55.7 onsite physician hours. There were 54 onsite physician hours documented for this week.
For the week of October 15, 2017, the reported patient census was 559. The facility was required to provide at least 55.9 onsite physician hours. There were 54 onsite physician hours documented for this week.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As a result of both Medical Doctors either being on a vacation or having an unforeseen family medical emergency outside of the country, we acknowledge the 1 hour shortage of time as per regulation for the weeks stated. To plan for any future unforeseen family or vacation request by a MD Soar has already hired an additional Physician Assistant who will work 2 days a week. This addition shall add a total of 16 additional medical hours. The additional Physician Assistant has been hired as of 12/15/17. The Human Resource Director shall monitor the completion of the hours by means of providing time sheets providing the additional hours are completed. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Seven client records were reviewed on January 17-18, 2018. As the transferring narcotic treatment program, the facility failed to transfer all required patient files to the receiving narcotic treatment program for client record # 2.
Client # 2 was admitted into treatment on 3/21/14 and was transferred to another narcotic treatment program on 7/10/17. The facility did not document the transfer of the following patient files to the receiving narcotic treatment program: medical and psychosocial summaries, urinalysis reports or summary, and the current status of the patient.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Regional Project Director shall complete an internal training on the transfer process by 4/11/18. Proof of the training shall be kept in the HR binder of the employee. The training shall address and state the need to send all of the medical and psychosocial summaries, urinalysis reports or summary, and the current status of the patient as outlined by regulations. The staff will be informed of the need to keep the fax confirmation with the transfer package within the patient chart to be proof of the package being sent. The staff will be informed of the need to send all of the required information even when the receiving provider states they do not wish to receive the information. Post training, all counselors shall bring a transfer package to a clinical supervisor for approval prior to being faxed to ensure all required documents are provided. All transfer patients shall be audited by a clinical supervisor at the time of closing a chart to ensure completion. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Seven client records were reviewed on January 17-18, 2018. Two of the seven client records were reviewed for the documentation of a psychosocial evaluation. The facility failed to complete a psychosocial evaluation during the intake process for client record # 5.
Client # 5 was admitted into treatment on 5/18/17 and was still active in treatment. A Biopsychosocial assessment was completed for the client on 5/18/17. The psychosocial evaluation documented in the client's record was completed on 7/17/17.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 3/5/18, Soar Corp has assigned a director supervisor to the intake department that will oversee all admissions and intake paperwork associated with the intake process. As of 4/1/18, the Clinical Supervisor assigned to the intake department will now complete a chart audit within the first 30 of all new admissions, to ensure all documentation is completed. Any occurrence of missing psychosocial evaluations will be identified in this manner. The Clinical Supervisor shall submit the correction to the assigned counselor and the counselor will have 1 week to resolve the issue. The request for correction shall be noted in a supervisory note, proof of the audits shall be kept by the clinical supervisor in a binder for review. This process shall now be ongoing and monitored by the regional director to ensure the clinical supervisor is completing the duty. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Seven client records were reviewed on January 17-18, 2018. The facility failed to document a treatment plan update at least every 60 days for client records # 1, 2, 4, 5, and 6.
Client # 1 was admitted into treatment on 11/7/14 and was still active in treatment. The first treatment plan update reviewed for the client's record was completed on 9/8/16. The subsequent treatment plan update documented in the client's record was completed on 6/2/17.
Client # 2 was admitted into treatment on 3/21/14 and was discharged on 7/10/17. The first treatment plan update reviewed for the client's record was completed on 12/20/16. The subsequent treatment plan update documented in the client's record was completed on 4/20/17.
Client # 4 was admitted into treatment on 3/18/15 and was discharged on 9/18/17. A treatment plan update was completed for the client on 3/9/17. A subsequent treatment plan update was completed for the client on 6/15/17.
Client # 5 was admitted into treatment on 5/18/17 and was still active in treatment. A comprehensive treatment plan was completed for the client on 6/18/17. The first treatment plan update documented in the client's record was completed on 10/1/17. Subsequent treatment plan updates were then completed for the client on 10/5/17 and 12/13/17.
Client # 6 was admitted into treatment on 11/21/14 and was still active in treatment. A treatment plan update was completed for the client on 8/20/17. A subsequent treatment plan update was completed for the client on 11/8/17.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
As of 3/14/18, the regional Project Director has established a clinical tracking excel grid which is now published in a network folder that is viewable to the clinical team including the counselors and clinical supervisors. This grid now lists the due dates for all treatment plans, case conferences, clinical annuals and evaluations. The clinical staff shall receive a formulized training within the next 30 days (4/30/18) on treatment plan formulation and how to use the treatment plan tracking system including the need to check the grid daily for changes. Post training, the clinical supervisors shall review outstanding treatment plans with their immediate supervisors and the review shall be documented in a supervisory note. The counselors shall turn in the completed treatment plan to the immediate supervisor who will approve the treatment plan and then update the tracking grid with the new due date. The use of the electronic format to check and track due date shall be ongoing. The regional director shall review the electronic grid monthly and discuss concerns as need with the clinical supervisors. Any concerns shall be documented in the clinical team meetings. |