INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14, 2008 through April 15, 2008 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 15, 2008.
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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 a review of personnel records, the facility failed to document monthly meetings for clinical supervisor #2 in two of two months where required. The clinical supervisor was hired February 2008 and monthly supervision was not documented for February or March 2008.
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Plan of Correction
Clinical Supervisor will receive monthly supervision as required. This will be provided by Director beginning immediately and ongoing per regulations. Director will provide monitoring. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of training documentation, the facility failed to document an overall training plan for the agency for the 2008 calendar training year.
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Plan of Correction
Training plan for 2008 for agency will be done immediately by Director. Future plans will be done in timely fashion by Director or desginee. Tx team will assist in making sure that plan is done as required by Pa Regs. |
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 records and training plans, the facility failed to document individual training plans that were appropriate to the employee's skill level in three of seven records reviewed, #2, 3 and 5. The section in the training plans that was to contain the individual training needs were blank in #2, 3 and 5.
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Plan of Correction
The Director will ensure that all training plans are reviewed at least annually, individualized, documented, and in employee's personnel file. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill records, the facility failed to document monthly fire drills in one of three months reviewed since the facility opened on December 6, 2007. A fire drill was not conducted in January 2008.
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Plan of Correction
The Director will ensure that the Safety Committee conducts and documents fire drills each month and in accordance with DOH. Documentation of such will be located in the Fire and Safety Manual. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill record, the facility failed to set off a fire alarm or smoke detector during fire drills in February and March 2008.
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Plan of Correction
The Director will ensure that Fire Drills are conducted within DOH standard. Documentation will be provided in the Fire & Safety Manual. SOAR will complete a request for an exception with the Division to utlize alternative methods for annoucing our monthly fire drills.
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709.22(d)(3) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(3) Describing the project's organizational structure.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document an updated organizational chart that showed the Project Director reported directly to the governing body. The organizational chart showed the corporation president, not the identified project director, as the individual who reports directly to the governing body.
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Plan of Correction
The Director will ensure that organizational chart is accurate and reflective of the reporting structure. The policy and procedure of the organizational structure will be updated and maintained with current information. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document that the project director prepared and updated the written manual.
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Plan of Correction
The Director will complete documentation of prepared and updated policy & procedures annually. Documentation of the Directors review will be placed with the policy & procedure manual. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of administrative documentation, the facility failed to document the goals and objectives for the 2008 calendar year.
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Plan of Correction
The Director will complete the Program Goals & Objectives for the 2008 calendar year. The Director will ensure that the Program Goals & Objectives are completed annually and timely. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of personnel records, the facility failed to document the project's efforts towards informing staff of their rights under 709.26(e)(1)-(3) in seven of seven personnel records reviewed, #1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
The Director will ensure that all employees have reviewed and completed the acknowledgment form of personnel rights. The Employee Acknowledgment Form will be maintain in the HR File. The Director will review all personnel records annually to ensure compliance with DOH standard 709.26 (e)(1)-(3). |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document complete medical histories in four of four records reviewed, #1, 2, 3 and 4. The client's family medical history and the client's medical symptoms were not documented in three records, #1, 2 and 3. The medical history was missing in one record reviewed, #4.
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Plan of Correction
The Director will ensure that the Medical Physician is trained on completion and documention of the client's medical history. Documentation of the client's medical history will be maintained the client's record. The Clinical Supervisor will complete chart aduits Quarterly to ensure proper documentation and compliance of medical histories. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document short and long-term goals for treatment stated in terms of measurable criteria in three of three records reviewed, #1, 2 and 3.
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Plan of Correction
The Director will ensure that Clinical Staff is provided additional training on Treatment Planning Documentation. Documentation of the training will forward to each personnel file. The Clinical Supervisor will ensure that treatment goals are measurable and address any additional training needs in individual supervision. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document counseling services being provided according to the individual treatment plan in one of three records reviewed, #2. The treatment plan indicated that the client was to receive 2.5 hours of individual treatment sessions per month. Client #2 received only .5 hours of individual treatment in March 2008.
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Plan of Correction
The Clinical Supervisor will ensure that all clients meet the required 2.5 hours of clinical services per month. The Clinical Supervisor will review with staff the need to provide, document, and the frequency of treatment for each individual client as per the individualized treatment plan. The Director and/or Clinical Supervisor will review clinical services provided to clients each month to ensure future compliance. |