INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on September 15, 2021 through September 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
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Plan of Correction
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704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of personnel records, the facility failed to ensure that at least one-half of each employee's training was provided by trainers not directly employed by the project in one of two applicable records reviewed. Employee #1 was hired as the project director on February 1, 2015. The personnel record documented the required 12 hours of training; however, all 12 hours documented were provided by staff within the project.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 9/27/21 an updated training grid has been established and will be maintained by the HR assistant. Quarterly, the training grid will be reviewed and an email will be sent quarterly to each staff member from the HR department notifying them of the total number of training hours completed and total number of hours needed. The first email notification shall be sent by 10/11/21 and the program director shall monitor for completion. The staff person reference shall complete 6 hours of external training by the close of the calendar year to ensure compliance |
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
Based on a review of the facility's policy and procedure manual, 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 2020 fiscal year. This is a repeat citation from the October 18, 2019 and July 30, 2020 annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An audit engagement letter and a statement from the owner was given to the DDAP reviewer at the time of the onsite inspection. The audit is expected to be completed by 10/31/2021. The audit will be available and given to DDAP staff during the next licensing inspection, prior to the expiration of the current license. The CEO will be responsible to ensure that the audit is completed within the time outlined |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of patient records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on informed and voluntary consent to release information forms in two of ten patient records reviewed.Patient #1 was admitted into the outpatient level of care on June 17, 2021 and was active at the time of inspection. A release of information form was signed and dated by the client; however, the consent form only identified that it was for "friends and family" and did not include the specific name of the person(s) to whom the disclosure would be made to. Patient #4 was admitted into the outpatient maintenance level of care on June 23, 2021 and was active at the time of inspection. A release of information form was signed and dated by the client; however, the consent form only identified that it was for "friends and family" and did not include the specific name of the person(s) to whom the disclosure would be made to. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 9/29/21, the "family and friends documentation" form noted has been removed from use at the facility. Within 30 days (10/30/2021) the program director of the facility shall complete an internal training on the 42 cfr and 255.5 state regulations. Within the training, a review of proper release format shall be completed to include the type of information and to whom information can be release to. Proof of training shall be kept in the staff members chart for review. Post training the program director shall audit and review a staff members releases during a monthly supervision session to ensure compliance is kept. The review process shall be ongoing by the program director. |
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
Based on a review of patient records, the facility failed to document the specific information to be disclosed on consent to release information forms in two of ten patient records reviewed.Patient #1 was admitted into the outpatient level of care on June 17, 2021 and was active at the time of inspection. A release of information form that was identified to be to "friends and family" of the patient was signed and dated by the client; however, the consent form did not document the specific information to be disclosed. Patient #4 was admitted into the outpatient maintenance level of care on June 23, 2021 and was active at the time of inspection. A release of information form that was identified to be to "friends and family" of the patient was signed and dated by the client; however, the consent form did not document the specific information to be disclosed.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 9/29/21, the "family and friends documentation" form noted has been removed from use at the facility. Within 30 days (10/30/2021) the program director of the facility shall complete an internal training on the 42 cfr and 255.5 state regulations. Within the training, a review of proper release format shall be completed to include the type of information and to whom information can be release to. Proof of training shall be kept in the staff members chart for review. Post training the program director shall audit and review a staff members releases during a monthly supervision session to ensure compliance is kept. The review process shall be ongoing by the program director. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of patient records, the facility failed to document the date, event or condition upon which the consent will expire on consent to release information forms in two of ten patient records reviewed.Patient #1 was admitted into the outpatient level of care on June 17, 2021 and was active at the time of inspection. A release of information form that was identified to be to "friends and family" of the patient was signed and dated by the client; however, the consent form did not document the date, event or condition of which the form would expire.Patient #4 was admitted into the outpatient maintenance level of care on June 23, 2021 and was active at the time of inspection. A release of information form that was identified to be to "friends and family" of the client was signed and dated by the patient; however, the consent form did not document the date, event or condition of which the form would expire.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 9/29/21, the "family and friends documentation" form noted has been removed from use at the facility. Within 30 days (10/30/2021) the program director of the facility shall complete an internal training on the 42 cfr and 255.5 state regulations. Within the training, a review of proper release format shall be completed to include the type of information and to whom information can be release to. Proof of training shall be kept in the staff members hr chart for review. Post training the program director shall audit and review a staff members releases during a monthly supervision session to ensure compliance is kept. The review process shall be ongoing 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 patient records, the facility failed complete and document a random urinalysis, for each patient, at least monthly in two of six applicable patient records reviewed.Patient #3 was admitted into the outpatient maintenance level of care on March 5, 2021 and was active at the time of inspection. There was no documentation that a random urinalysis was conducted for the months of May 2021, June 2021, July 2021, and August 2021.Patient #4 was admitted into the outpatient maintenance level of care on June 23, 2021 and was active at the time of inspection. There was no documentation that a random urinalysis was conducted for the month of August 2021.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 10/1/21, The Director of Nursing will run a "patient without a UDS report" from the EMR twice a month to identify the patients who have not completed the minimum urine drug screen requirements. Patients identified by this method shall be placed on hold to do so. Patients who refuse to complete a screening shall have a Non-billable note placed in their EMR record to document as such, and serve as proof that attempts for screening were made by staff. The process will be ongoing and will be monitored by the Director of Nursing to ensure completion. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to document an annual evaluation of each patient's status, which is to be completed by the patient's counselor and reviewed/signed by the medical director, in one of three applicable patient records reviewed. Patient #9 was admitted into the outpatient maintenance level of care on April 30, 2019 and was discharged August 23, 2021. The last annual clinical evaluation documented in the record was completed in April 2020.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 10/13/21, an EMR Tracking Grid will be established for the medical and clinical staff to track case conferences, clinical annuals, and bloodwork and ppd test. Weekly, the clinical supervisors will review the EMR Tracking Grid to identify clinical annual evaluations that are outstanding or need to be completed by a counselor and shall address this in the clinical supervision meetings. At the end of each month, the Quality assurance assistant will audit clinical annual evaluations and findings will be reported to the clinical supervisor for correction. The program director shall monitor for completion and this process will be ongoing. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
The facility failed to comply with plans of correction approved by the Department.As a result of the July 30, 2020 annual licensing inspection, the facility submitted a plan of correction stating that the financial audit would be completed annually in the first quarter of each year and shall supply a copy to the Regional Project Director. This plan of correction was approved by the Department on August 11, 2020. The facility did not complete the 2020 audit within the timeframe of the corrective action plan as the 2020 audit was not presented to Department staff during the on-site inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An audit engagement letter and a statement from the owner was given to the DDAP reviewer at the time of the onsite inspection. The audit is expected to be completed by 10/31/2021. The audit will be available and given to DDAP staff during the next licensing inspection, prior to the expiration of the current license. The CEO will be responsible to ensure that the audit is completed within the time outlined |