INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection, conducted on December 10 - 11, 2014 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.
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Plan of Correction
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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 ensure that each counselor met the qualifications for the position of counselor in one of fifteen records. The findings include:Fifteen personnel records were reviewed to ensure that each counselor met the qualifications for the position of counselor. The facility failed to ensure that each counselor met the qualifications for the position of counselor, specifically employee # 12.Employee # 12 was hired as a counselor on 8/5/13. Employee # 12 possesses a Bachelor's degree in Business Administration Marketing. The Bachelor's degree does not meet the educational requirements for the position of counselor.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor in question was moved back to the position of assistant counselor immediately until such time as the staff member meets the requirements to be a full Counselor. The Director of H.R. will ensure that this process is completed and a new job description indicating as such is completed. Clinical Supervisor will work with staff member to develop a plan that will lead towards becoming a full Counselor and will also monitor for compliance and provide the required supervision. Supervisor will update Director as to plan developed for staff member. The Director of H.R. will be given a copy of acceptable degrees for a counseling position and will screen all future resumes to meet this standard. Prior to any offer for employment, the regional director shall complete a second review of the qualifications to ensure qualification are met prior to employment. This process will start immediately and will be ongoing. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.The findings include:On December 8, 2014, the project's administrative records were reviewed for a financial audit. The project's fiscal year runs from January through December. The project failed to document the annual audit for the January through December 2013 fiscal year.These findings were reviewed with facility staff during the licensing process.This is a repeat citation. The facility was previously cited for non-compliance on 11/22/13.
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Plan of Correction
As of December 22, 2014, the Vice President has spoken to the board of SOAR CORP about the need to complete independent audits on the financial activities. The Vice President will be responsible for setting agency budgets. the CFO of Soar Corp will be responsible for ensuring that the audits are completed on a ongoing annual basis. These audits will be completed within the first 6 months of each year. The CFO will achieve these audits by retaining a independent audit company. The Vice President of Soar Corp will be a secondary check and balance and ensure the CFO completes the duty. The 2013 and 2014 audit shall be completed within the first 6 months of 2015 |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document in writing notification of admission and the initial dose given to the patient to the transferring narcotic treatment program in four of eight patient records reviewed. The findings include:Eight patient records were reviewed for transfer documentation on December 10 - 11, 2014. The facility failed to document notification of admission and the initial dose to the referring facility in four of eight patient records reviewed, specifically patient records # 3, 4, 5, and 6.The findings were reviewed with facility staff during the methadone monitoring inspection.This is a repeat citation. The facility was previously cited for non-compliance on 10/24/12 and 9/19/13.
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Plan of Correction
Clinical supervisors will ensure that all staff members receive a copy of the SOAR policy on transfers and review it with appropriate staff members during supervision. In addition, clinical supervisors will ensure through supervision and chart audits that the required documents have been obtained as required. Supervisors and Compliance will monitor throughout the year to ensure that the required paperwork is being both obtained from other facility and sent by SOAR Corp in a timely fashion. |