INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 8 and 9, 2009 licensure renewal inspection. The follow-up inspection was conducted on March 3, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 March 31, 2010.
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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.
This could not be re-evaluated due to not having access to the personnel records on March 3, 2010.
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Plan of Correction
As of 7/1/2009 the person in question was relieved of that position and is no longer the project director. He will remain on the Board only. The current Director has been appointed by the Board to also be the Project Director effective 7/1/2009. This individual does meet the qualifications as outlined in 704.5. |
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.
This could not be re-evaluated due to not having access to the personnel records on March 3, 2010.
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Plan of Correction
Employee in question has already completed the required one yr as a counselor assistant with the proper supervision by the clinical supervisor. A letter was prepared by the clin supervisor and placed in the employees files for review by DAPL when requested. |
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.
This could not be re-evaluated due to not having access to the personnel and training records on March 3, 2010.
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Plan of Correction
Director and Clin Sup will meet this week to review all employee files to make sure that all information is current. All employees of Soar will have their ind training plan current and in place by the end of this month. Director will monitor for compliance. |
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.
This could not be re-evaluated due to not having access to the personnel and training records on March 3, 2010.
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Plan of Correction
Dir and Clin Sup will meet this week to review all employee charts for compliance in this reg. An ind training plan will be done for all staff. This will be done annually with all staff having it done in Jan of each new year. All new emps will have one done upon hire and will then have one done every Jan. Director will oversee |
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.
This could not be re-evaluated due to not having access to the personnel and training records on March 3, 2010.
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Plan of Correction
Key for office and cabinet with personell files will be made available to Clin Sup and Admin Asst. All staff files are being reviewed by 3/31/2010 for complaince with DAPL regs. Any staff member that does not have these trainings will be given a memo by 4/15/2010 with clear instructions of what they need to do for trainings and the time frame in which to do it.Clin Sup will monitor all staff for compliance with trainings. |
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.
This could not be re-evaluated due to not having access to the personnel and training records on March 3, 2010.
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Plan of Correction
All emp files are being reviewed by 4/2/2010 week for complaince with DAPL regs. Any staff member that does not have these trainings will be given a memo by 4/15/10 with clear instructions of what they need to do and the time frames in which to do it.Clin Sup will monitor all staff charts for compliance in trainings. Emp in question was given ind memo with what they need to do in order to remain an emp here at Soar. Memo stated trainings to be obtained by 5/31/2010. |
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 outpatient caseload computation sheet, the facility failed to document that the FTE counselor caseload for counseling in outpatient programs did not exceed 35 active clients.
Findings:
The outpatient caseload computation sheet was reviewed on March 3, 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 #4 was 43/1.
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Plan of Correction
All counselor caseloads will be reviewed by Friday 3/19/2010 and checked for complaince in the counselor to pt ratio of 35 to 1. Clin Sup will adjust all caseloads so that no counselor exceeds the reg ratio of 35 to 1. Clin Sup will monitor for compliance during staff meeting at least once a month. |
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.
This will be a repeat citation because the facility failed to provide fire drill documentation on March 3, 2010.
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Plan of Correction
Dir will modify the fire drill forms to include a line where the staff member conduting the drill will have to check off what exit routes were utilized. Dir will number each and every door leading out for identification purposes. This will allow easy documentation regarding exits that were used. Dir will monitor for compliance through the course of the year. |
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 tour was conducted on March 3,2010 between 1:00 and 1:30 PM. The facility failed to secure the open and closed client records within locked storage containers. The closed client records were stored in an unlocked cabinet in a hall closet. The doors to this closet had been removed and the doors were observed stored in a counselor's office. The clinical supervisor acknowledged that the storage cabinets were not locked in both areas.
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Plan of Correction
All staff will be given a memo and signs posted regarding keeping file caninets locked and secure. Dir will issue warning to all staff regarding this lack of security as this falls under the responsibility of all staff who have access to this area. This will be addressed in next staff meeting with clear consequences discussed so that all staff will understand how important this is. Doors that were removed will be put back up with seperate locking system. Dir 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 the review of client records, the facility failed to document psychosocial evaluations in three of 12 client records.
The findings include:
Fourteen client records were reviewed on March 3, 2010. The facility failed to document a psychosocial evaluation in client record # 4, 5, and 12.
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Plan of Correction
All pt files will be reviewed over the next 2 weeks for compliance in this area. All clinical staff will be given memo regarding importance of completing psych-social in timely manner. Clin Sup will perform in-service training of psychsocial evals and will monitor charts through weekly supervision for compliance. |
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 complete record of service in six of fourteen client records.
Findings:
Fourteen client records were reviewed on March 3, 2010. A record of service was required in thirteen client records. The facility failed to document a record of service to include both individual and group sessions in client records #1, 4, 7, 8, 11, and 12.
The facility failed to complete a record of service in client record #1 and 12.
The facility failed to document group sessions on the record of service for client #4.
The facility failed to document group sessions after October 2, 2009 and they failed document individual sessions after September 17, 2009 on the record of service for client
#7.
The facility failed to document individual and group sessions after September 18,2009 on record of service for client #8.
The facility failed to document a record of services for client # 12 between March 24, 2009 and his discharge date, July 10, 2009.
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Plan of Correction
All pt files will be reviewed over the next 2 weeks for compliance in this area. All clinical staff will be given memo regarding importance of keeping a record of service up to date. Clin Sup will perform in-service training regarding what is required in all pt charts. This will be monitored through weekly supervision for compliance. |