INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 10-12, 2017, 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on staff interviews and a review of staff records conducted during the onsite inspection, the facility failed to document the required monthly meetings between newly hired or newly promoted clinical supervisors, and the staff person supervising the clinical supervisors in 2 of 2 staff records.Staff Person #5 was hired as a clinical supervisor on 5/31/2016, but the facility did not have documentation that the staff person attended the required meeting with his or her supervisor for the month June 2016.Staff Person #6 was promoted to clinical supervisor on 01/25/2016, but the facility did not have documentation that the staff person attended the required meetings with his or her supervisors for the months of February, March, April and May of 2016. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Effective immediately, the program director shall complete supervision with all new clinical supervisors of the program on a bi-weekly basis for their first 6 months of employment at the facility. The meeting shall be documented by completing a clinical supervision note that will be kept in a binder and signed by the program director and the clinical supervisor. To ensure completion, a quality assurance check shall be completed by the regional project director on a monthly basis to ensure sessions are completed and documented for all new supervisors. Any instance of missing or incomplete documentation found in the quality assurance check shall be addressed by the regional director to the program director. the check and balance will now be ongoing. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on staff interviews and a review of staff records conducted during the onsite inspection, the facility failed to to provide sufficient first aid coverage for all hours of operation.The facility did not have a staff person documented to be trained in First Aid training scheduled to work for dosing on 01/03/2017, from 5:30AM to 6:00AM. These findings were reviewed with the facility staff as part of the inspection process.
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Plan of Correction
Within the next 30 days, The Director of Human Resources shall located and arranged for a external trainer to come to this site to complete a first aid training for all staff. The Medical staff shall including the nurses and medical doctor shall complete this training. The onsite site training shall be scheduled and completed within the next 90 days. Proof of training by means of a training certificate and first aid card shall be Kept in the employees chart. Ongoing the Human Resource Director shall schedule set up a annual cpr and first aid training in the first quarter of each year for staff to attend to remain in compliance |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of facility records submitted during the presubmission process, the facility failed to document all of the required information in its fire drill records. The fire drill log for the fire drill conducted on 03/11/2016, does not document the length of the time of the drill, the time the drill was conducted or the exits routes used during the drill.These findings were reviewed with the facility staff as part of the inspection process.
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Plan of Correction
The regional project director shall provide a education training on fire safety documentation to the members of the health and safety committee who facilitate the fire drills. Within the training, required information for fire drills will be discussed and the procedure to document will be discussed. this training shall be completed by 3/3/17. Furthermore, all fire drill forms shall be reviewed by the health and safety committee in their quarterly meeting to ensure that the required information for fire drills is documented on the form. This review of the fire drill form shall be a ongoing system to ensure documentation accuracy. Any issues of insufficient documentation will be addressed in this review and a record of insufficiencies shall be kept in the health and safety meeting notes. |
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 a review of patient records conducted during the onsite inspection, the facility failed to document treatment plan updates every 60 days in 3 of 9 patient records reviewed.Patient #1 was admitted for treatment on 03/15/2016, and was an active patient at the time of the onsite inspection. The patient ' s individualized treatment plan was completed on 4/15/2016, but the there was no documented treatment plan update until 10/11/2016.Patient #3 was admitted for treatment on 06/02/2016, and was an active patient at the time of the onsite inspection. The patient ' s individualized treatment plan was completed on 6/26/2016, but the there was no documented treatment plan update at the time of the onsite inspection.Patient #8 was admitted for treatment on 12/14/2015. The patient ' s last documented treatment plan update was completed on 07/14/2016, but another treatment plan update was due on 09/14/2016, prior the patient ' s discharge on 09/28/2016. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Regional Project Director shall develop an excel spreadsheet on the Soar Share Drive to assist in tracking the due dates of treatment plan reviews. The spread sheet shall be sorted by a counselor's caseload, and shall automatically highlight treatment plans due within the next 30 days. During the counselor supervision sessions, the clinical supervisor shall review this tracking sheet with the counselor. The treatment plan grid shall be updated a new treatment plan due date by the supervisor. The review of the treatment plan grid will be ongoing in the individual supervision session and documented as such. Additionally on top of the treatment plan grid, Soar will increase its quarterly audits to 15% of the active charts. Findings of the audits shall be documented and turned into the clinical supervisors for corrections. Additionally, in terms of patient 3 the treatment plan referenced has been completed and signed by all members and is currently in the active patient's chart. the program director saw the oversight of this correction |