INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted October 15, 2019 through October 18, 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, 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policy and procedure manual during an onsite annual licensure renewal inspection conducted October 15-18, 2019, it was determined that the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Effective immediately, the regional project director shall include an annual signature page and statement to the project policies and procedures book. The annual signature page will be completed within the 1st quarter of each calendar year. The annual signature page will indicate the date of when changes, updates, and delineations of project policies and procedures were approved by the board of directors. The current signature page cited from the onsite inspection shall be completed in the next 15 calendar days (11/6/19) by the Regional Project Director. Ongoing, the regional project director shall monitor for completion. |
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.
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Observations
Based on the review of personnel records during an onsite annual licensure renewal inspection conducted October 15-18, 2019, it was determined that the facility failed to document an annual written individual staff performance evaluation for one out of five employees reviewed.
Employee #2 was employed on October 2, 2017 and was a current employee at the time of the inspection. A 90-day staff performance evaluation was completed on January 5, 2018 and therefore the annual evaluation was to be completed by January 5, 2019; however, a completed annual evaluation was not documented in the employee's record until October 2, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The employee in question was hired on 10/2/17; therefore the anniversary date of their employment will be Oct 2nd of each calendar year. Soar does not believe that the annual anniversary date for the employee should be calculated off of the completion date of the 90 day employment review, but off of the date the employee was hired by the facility. An annual evaluation based of the date of hire was completed for this employee on 10/2/19 and is noted as being completed within this report.
To address the rejection stating "other reason being an October 2018 annual evaluation was not completed or present at the time of the inspection, but the annual employee evaluation due for Oct 2019 was present for the onsite inspection" Soar has the following plan As of 6/1/19, The Human Resource Director has an employee excel grid to track the due dates of all annual and semi-annual employee reviews. HR Director will be responsible to check the employee grid on a weekly basis to identify upcoming employee reviews. The HR Director shall notify the Program Director and Site Supervisor by e-mail 2 weeks prior to the due date for the evaluation. The Program Director and Site Supervisor will complete the evaluation with the employee by the due date and submit it to the HR Director. The HR Director will then update the tracking date for the next review on the employee grid. This will be an ongoing check and balance system to ensure time of completion. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the project's unusual incident log during an onsite annual licensure renewal inspection conducted October 15-18, 2019, it was determined that the project failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving events that required the presence of police, fire or ambulance personnel.
On April 10, 2019, an event at the facility required the presence of police, fire or ambulance personnel. The incident was not reported to the Department until April 17, 2019.
On September 4, 2019, an event at the facility required the presence of police, fire or ambulance personnel. This incident was not reported to the Department until September 24, 2019.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director of the site shall complete a onsite training with all staff regarding incident reporting. The training shall cover the types of incidents that need to be reported, the time period to report incidents and the methods to report the incidents. The training shall be completed within the next 15 days (11/6/19) and proof shall be kept in the HR file of each employee. Ongoing, staff will notify the program director of a reportable incident on the same day it occurs. The program director shall file a report of a incident to the state and funding sources within 24 hours of being notified by staff. The program director shall be responsible to ensure that incident reports are completed and filed in a timely manner |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on the review of physician orders during an onsite annual licensure renewal inspection conducted October 15-18, 2019, it was determined that the program failed to have a narcotic treatment physician determine the proper patient dosage level in five out of the seven patient records reviewed.
Patient #1 was admitted on March 18, 2019 and discharged on September 1, 2019. On March 22, 2019, a certified registered nurse practitioner determined the patient's initial dose without the determination of a narcotic treatment physician. On March 29, 2019, April 5, 2019, April 12, 2019, May 31, 2019 and July 9, 2019, the patient's dose was increased by a certified registered nurse practitioner without the determination of a narcotic treatment physician.
Patient #2 was admitted on February 12, 2019 and discharged on May 31, 2019. On February 25, 2019, February 22, 2019 and March 1, 2019, the patient's dose was increased by a certified registered nurse practitioner without the determination of a narcotic treatment physician. On May 24, 2019 a taper for this patient was ordered by a certified registered nurse practitioner without the determination of a narcotic treatment physician.
Patient #3 was admitted on April 1, 2019 and was a current patient at the time of the inspection. On April 5, 2019, April 12, 2019 and June 7, 2019, the patient's dose was increased by a certified registered nurse practitioner without the determination of a narcotic treatment physician.
Patient #4 was admitted on August 20, 2019 and was a current patient at the time of the inspection. On August 22, 2019, August 23, 2019, August 30, 2019, September 6, 2019 and October 4, 2019, the patient's dose was increased by a certified registered nurse practitioner without the determination by a narcotic treatment physician.
Patient #7 was admitted on July 12, 2019 and discharged on August 6, 2019. On July 12, 2019, a certified registered nurse practitioner determined the patient's initial dose rather than a narcotic treatment physician. On July 19, 2019, July 26, 2019 and August 24, 2019, the patient's dose was increased by a certified registered nurse practitioner without the determination of narcotic treatment physician.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Soar Corp's Nurse Practitioner referenced in the citation has been granted an approved Mid Level Exception from SAMHSA and DDAP at our other 3 sites, which gives the Nurse Practitioner permission to determine a patient's initial dose and determine a patient's dosage level ongoing independent of a narcotic treatment physician. Soar filed for the mid level exception for the Warminster site, submitting the application to both DDAP and SAMHSA on 1/30/2019. Based on an e-mail from the Director, Division of Accountability and Program Improvement on 2/11/19, that the signature page was signed and sent to SAMHSA, Soar assumed the approval was forthcoming. Follow up e-mail contact with this Director revealed that the needed signature was not done until July 1, 2019. Soar proceeded using its best judgment while not delaying or limiting patient access to potential life saving care. Nonetheless effective immediately the CRNP will no longer make prescribing decisions until such time that the exception is approved. Going forward, the Regional Director will ensure the CRNP time does not exceed 2/3 of the required narcotic treatment physician time by monitoring the time sheets and schedule of the CRNP on a bi-weekly basis to ensure compliance. The CEO continues to make a concerted effort to recruit additional physicians to Soar.
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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.
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Observations
Based on the review of seven patient records, it was determined that the program failed to appropriately transfer one client's file that included 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 to the receiving facility.
Patient #1 was admitted on March 18, 2019 and transferred to another facility on September 1, 2019. The patient's transfer packet did not include the client's psychosocial, medical history and signed written consent form for the receiving facility.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The program Director shall complete an in house training within the next 15 days (11/6/19) regarding patient transfers. The training shall include all items to be included within the transfer package, including the psychosocial and ensuring the valid release is part of the transfer packet. The training will cover the need to fax all items to the receiving clinic and keeping the transfer coversheet and fax confirmation as proof of items sent. Ongoing, the program director shall review all transfer packets prior to being sent to another provider to ensure the packet is complete.
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715.29(4) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(4) The narcotic treatment program shall maintain documentation of the Department 's approval of an exception.
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Observations
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation. At the time of the onsite annual inspection, from October 15, 2019 through October 18, 2019, the program was found to be providing Buprenorphine services without prior approval from the Department.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Soar is providing Buprenorphine services for one client only. The prescribing CRNP does have the individual waiver. Soar failed to apply for an agency waiver. This was an administrative oversight. Soar did file the waiver application and supporting documentation via e-mail to DDAP on 10/22/19. Furthermore, no additional Buprenorphine services will be provided until such time the application is processed and approved. Regional Project director shall be responsible for ongoing monitoring for compliance. |