INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8 and 9, 2009 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on May 12, 2009.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document the qualifications for the position of project director.
Findings:
Nine personnel records were reviewed on April 8, 2009. The documentation of qualifications was required in nine personnel records. The facility failed to document that employee #1 met the qualifications for the position of project director.
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Plan of Correction
Program Director will meet with Project Director at Board mtg in May and inform him what is required. Project Director will submit a resume and educational background as required by DAPL. Director/Facility will arrange trainings needed and monitor for compliance. All other paperwork required for position will be obtained and placed in employee file. As Project Director is businessman with no D and A background, an exception will be requested where applicable regarding education qualifications. |
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.
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Observations
Based on a review of personnel records, the facility failed to document that counselors met the qualifications for the position of counselor in one of five personnel reviewed.
Findings:
Nine personnel records were reviewed on April 8, 2009. Documentation of qualifications for the position of counselor was required for five personnel. The facility failed to document that employee #8 met the experiential requirements for the position of counselor.
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Plan of Correction
Employee in question changed to counselor assistant and will complete another 6 months in that position. Clinical supervisor will provide required supervision and observe one hour per week of direct services provided. Supervisor will provide letter for employees file at the end of 12 months total time as assistant stating whether or not employee can then be a full counselor. New hire for human resource position, already in position, will ensure that all new hires meet the educational and experiential qualifications as required by DAPL. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of personnel and training records, the facility failed to document an assessment of staff training needs for six of eight personnel reviewed.
Findings:
Nine personnel and training records were reviewed on April 8, 2009. An assessment of training needs was required for eight personnel. The facility failed to document an assessment of staff training needs for employees #1, 3, 4, 6, 7 and 9.
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Plan of Correction
Cinical supervisor and director will complete assessment of training needs for all employees in question. Assessments will include all information as required by DAPL regulations. Clinical supervisor will complete all assessments for clinical staff every Dec. Director will do the same for all other staff in Dec of each year and at the time of hire for all new employees. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel and training records, the facility failed to document an individual training plan to include the potential resources for seven of nine employees reviewed.
Findings:
Nine personnel and training records were reviewed on April 8, 2009. An individual training plan was required for eight employees. The facility failed to document an individual training plan to include potential resources for subject areas for employees #3, 4, 5, 6, 7 and 8. The facility failed to document an individual training plan for employee #1.
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Plan of Correction
Clinical Supervisor will update all clinical staff annual training plans that will include all required information such as potential resources, time frames etc. Director will do the same for rest of staff and document in emp files as required. Ind training plans will be done every December for all employees as required. |
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 review of personnel and training records, the facility failed to document a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training for six of nine personnel reviewed.
Findings:
Nine personnel and training records were reviewed on April 8, 2009. A minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training was required for six employees. The facility failed to document a minimum of 6 hours of HIV/AIDS training for employees #1 and 9. The facility failed to document at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training for employee #1.
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Plan of Correction
All staff will receive a memo from clinical supervisor stating training requirements for all staff. Staff members in question from audit will be given specific memo giving them 7/31/09 time frame to obtain trainings identified. Clinical supervisor will monitor for compliance monthly. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel and training records, the facility failed to document at least 12 clock hours of training annually for one of two personnel records reviewed.
Findings:
Nine personnel records were reviewed on April 8, 2009. At least 12 clock hours of training was required for one employee. The facility failed to document at least 12 clock hours of training for the 2008 training year for employee #1.
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Plan of Correction
Clinical supervisor will issue memo immediately reminding all staff of their required annual training hours. Clinical supervisor will monitor staff training hours obtained to date and assist with obtaining any needed through weekly supervision during the year. Director to develop form in training binder for all employees that will track annual hrs obtained. Project Director to obtain training hours required by 12/31/2009. Director will monitor for compliance and ensure that training certificates are placed in project directors emp file. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing plan, the facility failed to document that the FTE counselor caseload for counseling in outpatient programs did not exceed 35 active clients.
Findings:
The staffing plan was reviewed on April 8, 2009. The facility failed to document that the FTE counselor caseload for counseling in outpatient programs did not exceed 35 active clients. The FTE counselor caseload for employee #7 was 40/1.
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Plan of Correction
Clinical supervisor will move caseloads to ensure that we meet the 35 to 1 ratio. A new counselor wass also hired the week after the audit took place which will assist with lowering the ratio. Clinical supervisor will monitor ratio throughout the year. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to document alternate exit routes to be used during fire drills.
Findings:
Fire drill records were reviewed on April 9, 2009. The facility failed to document alternate exit routes for fire drills conducted from May 2008 through March 2009.
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Plan of Correction
Director and Health and Safety staff member will identify doors in front as #1, #2 and #3. A different door will be identified on fire drill form as the one used during monthly fire drill. Doors going out of Medical Center will be identified as Doors A and B. Staff member doing fire drill will indicate which outside door is being used also. Safety committee will monmitor for compliance during quarterly meetings. Director will also monitor for compliance to ensure the safety of its patients and staff. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the physical plant inspection, the facility failed to secure client records within locked storage containers.
Findings:
The physical plant inspection was conducted on April 9, 2009 between 10 and 10:30 AM. The facility failed to secure client records within locked storage containers. The client records were stored in unlocked cabinets in the receptionist's office area.
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Plan of Correction
Memo issued by Director to all staff stating that filing cabinets with patient records are to be kept locked at all times. Admin Asst. instructed that these cabinets in her office are her responsibility and that she is to make sure that they are locked at all times during her 8 hr shift. Sign out form will be developed by Director that will clearly indicate who has been in the cabinet last to address individual staff who do not remember to lock cabinet. Both clinical supervisor and director will monitor for compliance. |
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 shall be in writing and shall 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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of nine client records reviewed.
Findings:
Eight client records were reviewed on April 8 and 9, 2009. The facility failed to obtain an informed and voluntary consent from the client for client #2 for the disclosure of information contained in the client record. The record contained three consents to release information which did not include the name of the person, agency or organization to whom disclosure was made.
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Plan of Correction
Clinical supervisor will provide a 1 hour minimum in-service to all clinical staff on the proper way to complete a release of information. Clinical Supervisor will also address releases in question at time of site visit with counselors responsible so that they can be corrected in the patients chart(s). Director will monitor these charts for compliance. Clinical Supervisor will address releases during quarterly audits of pt charts. Individual counselors will be addressed during weekly supervision as needed. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the facility failed to demonstrate efforts toward informing clients of their rights in eight of eight client records reviewed.
Findings:
Eight client records were reviewed on April 8 and 9, 2009. Efforts toward informing clients of their rights was required in eight client records. The facility failed to document efforts to inform clients of their rights to review their client records for clients #1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
Director will remove line in question regarding the removal of secondary information immediately. Director has completed new patient rights forms and they have already replaced the ones cited during site visit. Patients will be asked to sign the new form by their counselors so that all files will be updated and correct. clinical supervisor will monitor for compliance. |
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, the facility failed to document a psychosocial evaluation to include a composite picture, client problems/needs, assets/strengths, support systems,coping mechanisms, negative factors, attitude toward treatment and/or the counselor's conclusions/impressions in eight of eight client records reviewed.
Findings:
Eight client records were reviewed on April 8 and 9, 2009. Psychosocial evaluations were required in eight client records. The facility did not document a psychosocial evaluation in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
The facility did not document a psychosocial evaluation to include the client ' s assets/strengths in client records #1, 2, 3 and 6.
The facility did not document a psychosocial evaluation to include the client ' s support systems in client records # 1, 2, 4, 6 and 7.
The facility did not document a psychosocial evaluation to include the client ' s coping mechanisms in client records # 1, 2 and 7.
The facility did not document a psychosocial evaluation to include the client ' s negative factors in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
The facility did not document a psychosocial evaluation to include conclusions regarding the client ' s attitude towards and ability to participate in treatment in client records # 1, 5, 6, 7 and 8.
The facility did not document a psychosocial evaluation to include counselor conclusions/impressions in client records #1, 2, 3, 4, 6 and 7.
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Plan of Correction
In-service will be provided by Clinical Supervisor and Director that will address proper way to complete a psychosocial and its evaluation. Areas to be addressed will include clients assets/strengths, support systems, coping skills, negative factors regarding treatment, clients attitude and ability to participate in treatment, and counselors impressions/conclusions for the evaluation. Clinical Supervisor will audit all new client charts at 30 days to ensure compliance with the above. Issues with counselors will be addressed individually during weekly supervision. |
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 the review of client records, the facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan on the treatment plan update in five of eight client records reviewed.
Findings:
Eight client records were reviewed on April 8 and 9, 2009. An assessment of the client's progress in relationship to the stated goals of the prior treatment plan was required in five client records. The facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan in client records # 2, 3, 4, 5 and 7.
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Plan of Correction
Clinical Supervisor will provide in-service training and clinical staff will attend outside trainings on treatment plans. In-service will include how to address past treatment plan goals and provide assessment leading to new treatment plan(s). Director will monitor for compliance and clinical superviser will review during weekly supervision as needed and/or through the quarterly cliet file audit. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of services provided in three of eight client records.
Findings:
Eight client records were reviewed on April 8 and 9, 2009. A record of services provided was required in six client records. The facility failed to document a record of services to include group sessions in client records #2, 3 and 4.
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Plan of Correction
Director will develop new form that will be placed in all client files. Forms will be in front of progress note section and will allow for date, type of service provided, time and staff signature. Memo will be issued by Director that will address new form and proper documentation of provided services. Clinical supervisor will monitor for compliance through weekly supervision amd quarterly audits. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary to include the reasons for treatment, services offered, response to treatment and/or the client's status or condition upon discharge in three of eight client records reviewed.
Findings:
Eight client records were reviewed on April 8 and 9, 2009. A discharge summary was required in four client records. The facility failed to document a discharge summary to include reasons for treatment, services offered and client status in client records #5, 7 and 8.
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Plan of Correction
Director will edit form used for client discharge summary to include seperate section that will identify services provided, response to treatment and clients condition/status at time of discharge. Clinical supervisor will introduce new form to all clinical staff during weekly supervision. Clinical supervisor will monitor discharged clients charts for compliance within 30 days of a clients discharge. |