INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24-27, 2020 of SOAR Corp by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, SOAR Corp was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a reviewed of eighteen personnel records on December 24-25, 2020, the facility failed to ensure that staff obtained the required trainings within the required time in records, #5, 8, 7, 11 and 14.
Employee #5, admin. support, was hired 3/22/18 and the employee failed to complete the required TB/STD training.
Employee #7, admin. counselor, was hired 5/19/19 and the employee failed to complete the required HIV/AIDS training.
Employee #8, counselor assistant, was hired 11/26/18 and the employee completed the TB/STD training on 2/26/20 which was documented late.
Employee #11, counselor, was hired 11/28/18 and the employee failed to complete the required training within the required time. TB/STD was completed on 1/28/20 and HIV/AIDS was completed on 12/4/19.
Employee #14, counselor, was hired 11/1/18 and the employee failed to complete the required training within the required time. TB/STD was completed on 12/10/19 and HIV/AIDS was completed on 11/13/19.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee five and seven shall be scheduled to complete the training referenced within the next 60 days. Limited offerings of a training that meets the Department approved curriculum is currently resulting in the delay of registering. Human Resources shall monitor employee five and seven for completion of the training and place the training certificate in the file upon completion. Ongoing, Human Resources will continue to assist new staff in completing trainings to meet the state regulations within the allowable time frame. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on the physical plant inspection conducted on August 24, 2020, the facility failed to maintain all structures and fences on the grounds of the facility so as to be free from any danger to health and safety.
The fence surrounding the facility grounds was missing 5 post caps that left sharp edges on the post.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 8/26/2020, the 5 fence post caps cited in the report have been added to the fence by Soar's maintenance staff. Ongoing, Soar's maintenance staff shall inspect the fence monthly to ensure all caps are maintained. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection conducted on August 24, 2020, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.
The utility Rooms (HVAC) in suite 1 and the first floor Pavilion, had water leaks.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 8/26/2020, the clogged drain in the utility room on the first floor pavilion was discovered on 8/23/2020 by the regional director. As of 8/26/2020, the clogged drain in the utility room on the first floor pavilion was fixed and the water was dried up. Evidence of the issue being resolved was shown to the inspectors during the onsite visit. As of 8/26/2020, the HVAC unit owned by another tenant of the building that leaked into Soar's utility room in suite 1 was fixed and the water was dried up. Evidence of the issue being resolved was shown to the inspectors during the onsite visit. Ongoing, Soar's maintenance staff will continue to fix issues in real time and shall inspect all utility rooms weekly to ensure compliance |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection conducted on August 24, 2020, the facility failed to have hot water.
In suite #2 the bathroom sinks did not have hot running water in any of the bathrooms.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
the regional project director has scheduled for the hot water tank for the suite to be replaced by a qualified plumber. The hot water tank will be replaced by 9/25/2020. Ongoing, Soar's maintenance staff will continue to fix issues in real time and shall inspect all restrooms weekly to ensure hot water systems are in compliance. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on the physical plant inspection conducted on August 24, 2020, the facility failed to have clearly indicated exits using signs.
The facility made changes to the rooms and closets at the site but did not update the diagrams to match the changes at the facility.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The regional project director shall modify the existing floor plan / exit plan sign for the second floor pavilion to remove the hall closet referenced in the observation. The program director and regional project director shall post the corrected floor plan in the hallway and offices of the suite by 9/18/2020.
The regional project director shall modify the existing floor plan / exit plan for suite 8-10 to show the change of making two offices into one group room. The program director and regional project director shall post the corrected floor plan in the hallway and offices of this suite by 9/18/2020. Ongoing the program director shall be responsible to update and post floor plan diagrams to match the changes that may occur at the facility
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705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on the physical plant inspection conducted on August 24, 2020, the facility failed to light interior exits and stairs.
The fire exit hallway in suite #1 had lights bulbs burned out at the front of the hallway.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 8/26/2020, the light bulbs referenced in the observation have been replaced by Soar's maintenance staff. Evidence of the issue being resolved was shown to the inspectors during the onsite visit. Ongoing, Soar's maintenance staff shall inspect the emergency hallway weekly ensure the hallway and lights are maintained appropriately |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of the fire drill record conducted on August 24, 2020, the facility failed to ensure the that drills were conducted on different times of the day and on different staffing shifts.
Fire drills reviewed July 2019 through August 2020.
All the fire drills were conducted on the second shift between the hours of 11:30 am and 2:30 pm, the hours of operation is 6:00 am to 2:00 pm. There were no fire drills recorded before 11:30 am.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 9/2/2020, the regional project director has issued a instructional memo by e-mail to the management team of the facility. The memo states that the program director and supervisory staff will be responsible to ensure that 50% of the monthly drills are completed between the am hours from 6am to 10:30am and the other 50% of the monthly drills are completed between the am hours from 10:30am to 2:30pm. Additionally, the program director and supervisory staff will be responsible to ensure that there is a least one completed drill for each day of the week, including the weekends. Ongoing, on a quarterly basis, the program director will review the documented drills to verify the drills are completed at different times of the day and night and on different staffing shifts to remain in compliance with the regulation. |
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 the physical plant inspection conducted on August 24, 2020, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
Group room windows in suites 8, 2, and 1 were covered, but the blinds where too small and you could see inside the group room through the side of the blinds from the hallway.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 8/26/2020, Soar Corp added window tint to all of the windows with blinds in the group room of suite 8. Evidence of the issue being fixed was shown to the reviewers during the onsite visit. Soar's maintenance staff is now scheduled to place the window tint on all windows in the suite 2 and suite 1 group rooms by 9/25/2020. Ongoing, the regional project director shall ensure that both a window tint and blind are placed in any window of a counseling room to ensure privacy and to ensure a counseling session cannot be seen outside the counseling room |
705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection conducted on August 24, 2020, the facility failed to keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F
There were no thermometers in any of the refrigerators or freezers at the facility, however food was found in them all.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Soar Corp has purchased thermometers for all of the employee refrigerators and freezers at the facility that is used by its employees for food storage. Soar's maintenance staff shall place all of the thermometers in the employee refrigerators and freezers by 9/4/2020. Ongoing, Soar's maintenance staff shall inspect the refrigerators and freezers monthly to ensure the temperatures are maintained appropriately |
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
Administrative records were reviewed for documentation of an annual fiscal audit during the facility's licensing renewal inspection, conducted on August 24-27, 2020. 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, 2019, 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.
This is a repeat ciation from the January 2019 and October 2019 licensing inspections.
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Plan of Correction
The audit shall be scheduled by the CEO within the next 60 days (11/2/2020)and the CEO shall be responsible to ensure the scheduled audit is completed. The audit will be made available to the department upon request. Ongoing, the CEO will be responsible to ensure the annual audit is completed after the close of each fiscal year. |
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.
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Observations
Based on a review of client records on August 25-27, 2020, the facility failed to obtain an informed and voluntary consent in three of twelve client records.
Client #6 - The following consent to release forms all dated June 26, 2020 was signed by the client but failed to have the witness sign those consents. Additionally, they failed to also include whether the client was offered a copy or not.
Government Agencies (2 consent to release forms
Emergency Contact
Funding Source (2 consent to release forms)
Laboratories (3 consent to release forms)
Client #7 - Client identifying information was sent out to a provider on December 16, 2019, but there was no consent to release for that provider.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director will hold training on confidentiality and proper release formulation within the next 45 days (10/16/2020). The training will be mandatory for all clinical and intake staff. The training will cover the 255.5 regulation, and release completion including proper signatures, offering copies and properly indicating release forms with the name of the person, agency or organization to which disclosure is to be made. Training certificates shall be kept in the HR binder of each employee to serve as proof of training. Post training, The Program director and Clinical supervisor shall complete audits monthly on 10% of the charts to identify and issues with ROI's. If an issue is noted the clinical supervisor shall return the chart to the counselor for correction and it will be documented in a supervisor meeting. The audit process shall be ongoing.
The program Director shall be responsible to correct the consent forms where possible for patients # 6 by 10/16/2020.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records on August 25-27, 2020, the facility failed to document a notice of termination in client record #7.
Client #7 was involuntary discharged on December 9, 2019 and the notice of termination letter that was documented in the client's record was signed and dated almost 2 months after the client's discharge by the supervisor on February 29, 2020. There were no signatures from the client or counselor showing that the client was given a notice for the reason for termination.
The citation was reviewed with facility staff during the licensing inspection
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Plan of Correction
The program Director shall complete an in house training on discharges and involuntary discharges within 45 days (10/16/2020) with all of the clinical staff and supervisors of the facility. Proof of the training shall be kept in the employee's HR binder. During the training staff will be educated on the proper completion of the discharge summery, termination of treatment notices, administrative discharge forms (709.33 a) and also on the client process to request reconsideration of a decision to terminate treatment (709.33(b). Staff will also be educated on the time frames for completing these documents and on proper signatures for the documents. The program director will also complete a second in house training by 10/2/2020, with the clinical supervisors entitled treatment termination process to educate the supervisors on the standards for discharge, client appeals and steps to review discharges. Post training, the clinical supervisor shall review the discharges generated by a counselor. The review of the discharges shall occur during a supervision session. The clinical supervisor shall document the review of the discharges and the recommendations for improvement within the supervision note of the employee. The review of the discharges within a supervision session shall be ongoing to ensure compliance |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records on August 25-27, 2020, the facility failed to document a notice of termination in client record #7.
Client #7 was involuntary discharged on December 9, 2019 and the notice of termination letter that was documented in the client's record was signed and dated almost 2 months after the client's discharge by the supervisor on February 29, 2020. There were no signatures from the client or counselor showing that the client was given a notice of their termination and their right to request reconsidertion of their termination.
The citation was reviewed with facility staff during the licensing inspection
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Plan of Correction
The program Director shall complete an in house training on discharges and involuntary discharges within 45 days (10/16/2020) with all of the clinical staff and supervisors of the facility. Proof of the training shall be kept in the employee's HR binder. During the training staff will be educated on the proper completion of the discharge summery, termination of treatment notices, administrative discharge forms (709.33 a) and also on the client process to request reconsideration of a decision to terminate treatment (709.33(b). Staff will also be educated on the time frames for completing these documents and on proper signatures for the documents. The program director will also complete a second in house training by 10/2/2020, with the clinical supervisors entitled treatment termination process to educate the supervisors on the standards for discharge, client appeals and steps to review discharges. Post training, the clinical supervisor shall review the discharges generated by a counselor. The review of the discharges shall occur during a supervision session. The clinical supervisor shall document the review of the discharges and the recommendations for improvement within the supervision note of the employee. The review of the discharges within a supervision session shall be ongoing to ensure compliance |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of client records on August 25-27, 2020, the facility failed to verify the individual's identity in client record #9.
Client #9 was admitted on April 21, 2020 and discharged on June 7, 2020.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 9/4/2020, the regional project director has issued an instructional memo that outlines establishing client identity during the intake process. Within the memo, a list of acceptable identifications that can be used as part of the intake process has been issued for staff to follow. First all patients who present for an admission, intake or screening must have a form of government issued photo license and allow Soar Corp's intake staff to make a copy of the identification. Second, the program director and clinical supervisors shall be responsible to complete a chart audit on all new admissions within 2 weeks of the admission date to ensure an identification is part of the chart record. Any missing identification found shall be corrected within 1 week of the audit date. The procedures outlined in the memo shall be in effect as of 9/21/2020 |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of client records on August 25-27, 2020, the facility failed to document that a face-to-face determination was completed by a narcotic treatment physician in two client records.
Client #6 was admitted on June 26, 2020 and discharged on November 24, 2019.
Client #12 was admitted on May 6, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MD completed the documents to verify a 1 year history of an addiction but failed to sign and date the documents for client number 6 and client number 12. The missing signature from the MD on the 1 year history of addiction form for client 6 and 12 shall be signed by the MD by 9/18/2020 and placed back into the patient record. Moving forward, the program director shall complete a chart audit review on all new intakes within 2 weeks of the admission date to verify that all forms are signed and completed correctly. Deficiencies noted in this review shall be corrected by the program director. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of client records on August 25-27, 2020, the facility failed to either document an initial drug screening or random urinalysis in two client records.
Client #11 - was admitted on June 15, 2018 and discharged on June 25, 2020. The facility failed to document a monthly urine for the month of June 2018.
Client #12 - was admitted on May 6, 2020 and the facility failed to document an initial urine, the first urine was completed on June 15, 2020.
The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
The missing UDS screen for client 6 and 12 shall be printed out from the lab site and placed back into the patient record by 9/18/2020. Moving forward, the program director shall complete a chart audit review on all new intakes within 2 weeks of the admission date to verify that all admission forms are signed and completed, the physical and documentation of addiction is signed and complete and that the initial Urine Drug Screen result is within the client record. Any deficiencies noted in this review shall be corrected by the program director. The process of completing internal audits on the new admission charts shall start on 9/18/2020 and be ongoing by the program director. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of client records on August 25-27, 2020, the facility failed to document the initial intake physical examination in two client records.
Client #6 was admitted on June 26, 2020 and discharged on November 24, 2019.
Client #12 was admitted on May 6, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The MD completed the initial intake physical document but failed to sign and date the document for client number 6 and client number 12. The missing signature on the initial intake physical documents for client 6 and 12 shall be signed by the MD, and placed back into the patient record by 9/18/2020. Moving forward, the program director shall complete a chart audit review on all new intakes within 2 weeks of the admission date to verify that all forms are signed and completed correctly. Deficiencies noted in this review shall be corrected by the program director. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on a review of client records on August 25-27, 2020, the facility failed to document in the client record the result of their blood work in two client records.
Client #6 was admitted on June 26, 2020 and discharged on November 24, 2019.
Client #12 was admitted on May 6, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 9/4/2020, the regional project director has issued an instructional memo regarding the collection of blood work with the following procedures to document client non-compliance with a blood work request. First, the nurses will now write a non-billable note on the date a blood work request slip is given to a client to document the referral for testing. Second, the nurses will now write a non-billable note reflect significant non- compliance with testing follow up. The program director shall be responsible to address continued non- compliance with testing request and document interventions used to address. The charge nurse will be responsible to ensure nursing documentation is completed as outlined. The new system will be in effect within 30 days 10/4/2020 to allow notification of staff. Both patient 6 and 12 will be given new request for blood work and should complete it within 30 days |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on August 25-27, 2020, the facility failed to evaluate the client in four of twelve client records reviewed.
Client #6 was admitted on June 26, 2020 and as of today the facility failed to document a psychosocial evaluation.
Client #9 was admitted on April 21, 2020 and the psychosocial evaluation was completed on May 21, 2020. The psychosocial evaluation reviewed only stated what the client reported with no clinical evaluation in the following areas: Assets & Strengths, Problems, Needs, Negative Factors, Coping Skills, Attitudes towards Treatment, Coping Mechanisms and Mental Health Needs.
Client #10 was admitted on May 29, 2020 and the psychosocial evaluation was documented and signed on July 3, 2020 a day after the clients discharge of July 2, 2020.
Client #12 was admitted on May 6, 2020 and the psychosocial evaluation was completed on June 6, 2020, but the evaluation only documented what the client reported with no clinical evaluation.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program Director shall complete an in house training on the proper completion of the psychosocial evaluation within 45 days (10/16/2020) with all of the clinical staff of the facility. Proof of the training shall be kept in the employee's HR binder. During the training staff will be educated on each of the 13 domains of the evaluation and the content for each domain. The training will focus on removing client statements from the information and the need to formulate clinical impressions within the domain being reviewed. The training will also focus on time frames for completion, and establishing proper signatures and dates on the documents. Post training, the clinical supervisor shall review a sample of the clinical evaluations generated by a counselor. The review of the notes shall occur during a supervision session. The clinical supervisor shall document the review of the clinical evaluation and the recommendations for improvement within the supervision note of the employee. The review of the clinical evaluations within a supervision session shall be ongoing to ensure compliance. Client 6 psychosocial evaluation noted as not being documented shall be placed in the client record within the next 2 weeks (9/18/2020)
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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.
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Observations
Based on a review of client records on August 25-27, 2020, the facility failed to document a treatment plan update in two of twelve client records reviewed.
Client #8's treatment plan updates dated November 1, 2019, July 1, 2019 and May 1, 2019 did not document any changes with stated goals from the comprehensive treatment plan and no update was documented for those stated goals. Additionally, the counselor nor the client signed or dated the treatment plan updates, but the supervisor signed February 29, 2020.
Client #11's treatment plan updates dated July 18, 2020 and May 18, 2020 were identical with no update to those goals. Additionally, treatment plan updates dated February 17, 2020 and November 27, 2019 were also identical with no update to those stated goals.
Client #12's treatment plan update dated August 6, 2020 did not address an update to the stated goals, the treatment plan update was just a copy of the client's comprehensive treatment plan dated June 6, 2020.
The findings were addressed with facility staff during the licensing inspection.
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Plan of Correction
The program Director shall complete an in house training on treatment plan formulation within 30 days (10/2/2020) with all of the clinical staff and supervisors of the facility. Proof of the training shall be kept in the employee's HR binder. During the training staff will be educated on goal formulation, steps to document progress or the lack of progress on the goals and on the development and modifications of treatment interventions for goals. Staff will be educated on the time frames for treatment plans and on proper signatures for treatment plans. The program director will also complete an second in house training by 10/2/2020, with the clinical supervisors entitled treatment plan review process to educate the supervisors on the standards for treatment plan review. Post training, the clinical supervisor shall review the treatment plans generated by a counselor. The review of the treatment shall occur during a supervision session where the supervisor shall compare the new plan to the previous plan to verify updates have been completed. . The clinical supervisor shall document the review of the treatment plans and the recommendations for improvement within the supervision note of the employee. The review of the treatment plans within a supervision session shall be ongoing to ensure compliance |
709.93(a)(5) LICENSURE Client records
709.93. 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:
(5) Progress notes.
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Observations
Based on the review of client records on August 25-27, 2020, the facility failed to clearly document a plan in several progress notes reviewed for client #11.
Client #11 was admitted on June 15, 2020 and the following progress notes only documented the next session with no plan; July 1, 2020, July 14, 2020, July 23, 2020, July 29, 2020, August 6, 2020, August 12, 2020 and August 19, 2020.
The finding was addressed with the facility during the licensing inspection.
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Plan of Correction
The program Director shall complete an in house training on DAP note formulation within 30 days (10/2/2020) with all of the clinical staff of the facility. Proof of the training shall be kept in the employee's HR binder. During the training staff will be educated on the need to add further details in the plan that indicate recommendations given to a patient, statements of homework given to a patient, statements on additional resources given to the patient and a statement to indicate the next time and date for the next session. Post training, the clinical supervisor shall review a sample of the DAP notes generated by a counselor. The review of the notes shall occur during a supervision session and at a minimum of once per month for the counselor. The clinical supervisor shall document the review of the DAP notes and the recommendations for improvement within the supervision note of the employee. The review of the DAP notes within a supervision session shall be ongoing to ensure compliance |
709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on a review of client records on August 25-27, 2020, the facility failed to document a follow-up in six of twelve client records reviewed.
The follow-up form documented only showed that it was completed on this day, but the survey wasn't filled out and the survey form failed to indicate when the form was sent out to the client.
Client #5 was discharged on June 3, 2020 and the follow-up form date documented was July 3, 2020.
Client #6 was discharged on July 16, 2020 and the follow-up form date documented was August 16, 2020.
Client #7 was discharged on December 9, 2019 and the follow-up form date documented was January 9, 2020.
Client #8 was discharged on November 24, 2019 and the follow-up form date documented was December 24, 2019.
Client #9 was discharged on June 7, 2020 and the follow-up form date documented was July 7, 2020.
Client #10 was discharged on July 2, 2020 and the follow-up form date documented was August 2, 2020.
The citations were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The regional project director shall modify the current discharge follow up form by 9/21/2020 to add a section indicating a date of when the form was sent to a patient's home address. To increase the rate of obtaining a completed and returned follow up form post discharge, Soar Corp shall include a self- addressed return envelope with a postage stamp attached to it within the discharge follow up sent to a patient. Any returned follow ups that are returned shall be kept within the discharge follow up binder. The intake department will be responsible for completing the discharge follow up as outlined and the program director shall monitor the process to ensure proper completion. As of 9/3/2020, the regional project director has issued an instructional memo by e-mail to the management team of the facility and intake department outlining the change in procedure. The new procedure will be in effect as of 9/21/2020. |