INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 4, 2022 and November 7, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SOAR Corp - Warminster 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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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on an administrative review, the facility failed to ensure that time provided by the certified registered nurse practitioner did not exceed two-thirds of the required narcotic treatment physician time.
During the week of July 4, 2022, the patient census was 83 which required 8 total narcotic treatment physician hours, with no more than 5.5 of those hours to be provided by a certified registered nurse practitioner. The narcotic physician provided 0 hours and the certified registered nurse practitioner provided 8 hours.
During the week of July 11, 2022, the patient census was 80 which required 8 total narcotic treatment physician hours, with no more than 5.5 of those hours to be provided by a certified registered nurse practitioner. The narcotic physician provided 0 hours and the certified registered nurse practitioner provided 8 hours.
During the week of July 25, 2022, the patient census was 78 which required 7 total narcotic treatment physician hours, with no more than 4.5 of those hours to be provided by a certified registered nurse practitioner. The narcotic physician provided 0 hours and the certified registered nurse practitioner provided 7 hours.
During the week of August 8, 2022, the patient census was 79 which required 7 total narcotic treatment physician hours, with no more than 4.5 of those hours to be provided by a certified registered nurse practitioner. The narcotic physician provided 0 hours and the certified registered nurse practitioner provided 7 hours.
During the week of August 22, 2022, the patient census was 71 which required 7 total narcotic treatment physician hours, with no more than 4.5 of those hours to be provided by a certified registered nurse practitioner. The narcotic physician provided 0 hours and the certified registered nurse practitioner provided 7 hours.
During the week of September 5, 2022, the patient census was 75 which required 7 total narcotic treatment physician hours, with no more than 4.5 of those hours to be provided by a certified registered nurse practitioner. The narcotic physician provided 0 hours and the certified registered nurse practitioner provided 7 hours.
During the week of September 19, 2022, the patient census was 77 which required 7 total narcotic treatment physician hours, with no more than 4.5 of those hours to be provided by a certified registered nurse practitioner. The narcotic physician provided 0 hours and the certified registered nurse practitioner provided 7 hours.
During the week of October 10, 2022, the patient census was 73 which required 7 total narcotic treatment physician hours, with no more than 4.5 of those hours to be provided by a certified registered nurse practitioner. The narcotic physician provided 0 hours and the certified registered nurse practitioner provided 7 hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 10/3/22, the agency has hired an additional full time APRN. She will be working in all SOAR locations. As of result of this hire, MD hours for the Warminster site will total 24 hours per week. The doctor hours will be solely completed by a MD. This is effective as of 11/14/22. The Regional Director and QI Director shall monitor for compliance |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to document that each patient received an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in five of six applicable patient records reviewed.
Patient #2 was admitted on December 4, 2020 and was discharged on September 22, 2022. The record documented 0 hours of psychotherapy for the months of June and July 2022 and 2 hours of psychotherapy for the month of August 2022.
Patient #3 was admitted on November 3, 2021 and was discharged on August 21, 2022. The record documented 1 hour and 30 minutes of psychotherapy for the month of June 2022.
Patient #4 was admitted on August 7, 2020 and was discharged on October 5, 2022. The record documented 1 hour of psychotherapy for the months of May and July 2022.
Patient #5 was admitted on April 15, 2022 and was active at the time of inspection. The record documented 2 hours of psychotherapy for the month of August 2022 and 1 hour and 30 minutes of psychotherapy for the month of September 2022.
Patient #8 was admitted on June 16, 2022 and was active at the time of inspection. The record documented 1 hour of psychotherapy for the months of August and September 2022 and 0 hours of psychotherapy for the month of October 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following process will be in effect as of 11/15/22 and shall be ongoing to address the deficiency noted. Every two weeks, the clinical supervisor will now run the "patients not counseled report" to identify patients who have not completed the required psychotherapy hour or hours as required by regulation. The clinical supervisor and / or counselor shall place the patient on hold for treatment completion. Continued non-compliance with, patient no shows for, or cancellations of scheduled treatment sessions shall be documented on a non-billable note by the primary counselor. The non-billable notes shall be kept in the patient's EMR and serve as proof that attempts for sessions were made by staff. The process will be monitored by the program director to ensure completion. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment in two of two applicable patient records reviewed.
Patient #6 was admitted on May 17, 2019 and was active at the time of inspection. The record documented 0 hours of psychotherapy for the month of July 2022.
Patient #7 was admitted on August 6, 2019 and was active at the time of inspection. The record documented 0 hours of psychotherapy for the months of May, June, and July 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following process will be in effect as of 11/15/22 and shall be ongoing to address the deficiency noted. Every two weeks, the clinical supervisor will now run the "patients not counseled report" to identify patients who have not completed the required psychotherapy hour or hours as required by regulation. The clinical supervisor and / or counselor shall place the patient on hold for treatment completion. Continued non-compliance with, patient no shows for, or cancellations of scheduled treatment sessions shall be documented on a non-billable note by the primary counselor. The non-billable notes shall be kept in the patient's EMR and serve as proof that attempts for sessions were made by staff. The process will be monitored by the program director to ensure completion. |
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 narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in two of two applicable patient records reviewed.
Patient #1 was admitted on August 30, 2022 and was discharged on September 22, 2022. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date the initial dose was given.
Patient #5 was admitted on April 15, 2022 and was active at the time of inspection. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date the initial dose was given.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All transfers-in will be monitored weekly. The Intake Staff will send all first dose verifications to the sending program. The Program Director will audit all new admissions, within 7 days to ensure compliance. This process will begin on 11/21/22 and will be ongoing. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and reviewed, dated, and signed by the medical director in three of four applicable patient records reviewed.
Patient #4 was admitted on August 8, 2020 and was discharged on October 5, 2022. An annual evaluation of the patient's status was completed by the counselor on August 6, 2021. The next annual evaluation of the patient's status was due no later than August 6, 2022; however, the evaluation was not completed prior to discharge.
Patient #6 was admitted on May 17, 2019 and was active at the time of inspection. The annual evaluation of the patient ' s status was completed by the counselor on August 31, 2022; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient #7 was admitted on August 6, 2019 and was active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on August 26, 2022; however, the evaluation was not reviewed, dated, and signed by the medical director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director will send an instructional memo to all medical and clinical staff, outlining the appropriate process for completing a clinical annual evaluation. The memo will state the Medical Director must sign all clinical annual evaluations. The memo will be sent within 30 days (12/15/22). In an effort to ensure compliance, the QA department will audit clinical annual evaluations for completion, and appropriate signatures. |
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 client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in four of seven applicable client records reviewed.
Client #3 was admitted on November 3, 2021 and was discharged on August 21, 2022. A treatment plan update was completed on December 3, 2021 and the next update was due no later than February 3, 2022; however, the update was completed on February 10, 2022.
Client #5 was admitted on April 15, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on May 15, 2022 and the first update was due no later than July 15, 2022; however, the update was completed on July 20, 2022. Additionally, the next update was due no later than September 20, 2022; however, the update was completed on September 30, 2022.
Client #6 was admitted on May 17, 2019 and was active at the time of inspection. A treatment plan update was completed on May 2, 2022 and the next update was due no later than July 2, 2022; however, the update was completed on July 18, 2022.
Client #7 was admitted on August 6, 2019 and was active at the time of inspection. A treatment plan update was completed on May 23, 2022 and the next update was due no later than July 23, 2022; however, the update was completed on August 1, 2022. Additionally, the next update was due no later than October 1, 2022; however, the update was not completed as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director/Clinical Supervisor will run the tx plan due report, weekly. The Program Director/Clinical Supervisor will email this report to the counselors. The Program Director/Clinical Supervisor will run the tx plan due report at the end of the week to ensure compliance. Any deficiencies will be reviewed in clinical supervision. This is will be in effect beginning 11/21/22. |