INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 27, 2021 through April 30, 2021, by staff from the Bureau of 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.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on the Staffing Requirement Facility Summary Report submitted on April 16, 2021, the facility failed to provide a comprehensive list of their nursing staff. Time sheets were submitted for nursing staff who were not identified on the report.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5/24/21, a QI assistant has been hired for the agency. The QI assistant will now shall verify and establish a comprehensive list of any nurse who may have worked a shift within a time period requested, with the Nursing Supervisor and HR. The comprehensive list established by the QI assistant will then be placed on the staffing grid for review. The system will start as of 6/30/21 |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of documents submitted on April 16, 2021, the facility failed to supply documentation from the counselor assistant to the facility director identifying how the counselor assistant is working toward counselor status. This is to be documented upon completion of each calendar year.
Employee # 10 - hired 7/9/19
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director or the Clinical Supervisor will collaborate with the Counselor Assistant to provide and review the training plan, by 12/31, for the upcoming calendar year. The annual written review that is currently missing will be completed by 6/30/21. The program director will monitor to ensure completion |
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 on April 27, 2021 through April 30, 2021The facility failed to supply documentation of individual training plans for 7 employees. Per the Staffing Requirement Facility Summary Report, these plans were developed on January 2, 2021. The facility training year runs from January to December.
Employee #3 was hired 11/26/18
Employee #4 was hired 3/13/20
Employee #16 was hired 10/1/19
Employee #20 was hired 9/14/18
Employee #22 was hired 3/22/18
Employee #26 was hired 4/10/13
Employee #29 was hired 12/15/17
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All training plans will be submitted prior to 12/31, for the next calendar year. All missing training plans will be completed by 6/30/21. An ongoing tracking grid will be established and monitored, monthly, by the HR department. The program director will monitor to ensure completion |
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 records conducted on April 27, 2021 through April 30, 2021, the facility failed to supply documentation of staff members completing the required minimum 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training.
Employee #7, a counselor, was hired on 5/9/19 and there was no documentation that they completed the HIV/AIDS training.
Employee #16, a counselor, was hired on 10/1/19 and there was no documentation that they completed the TB/STD training.
This is a repeat citation from licensing inspections done 8/24/20 and 10/4/19.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
HIV training was conducted, via the web, on 4/30/21 and 5/7/21. TB/STD training was conducted via the web on 4/22/21. An ongoing tracking grid will be established and monitored, monthly, by the HR department. Ongoing, each staff member will receive an email from the HR department updating them on missing required missing trainings that need to be hired within the first year of hire. This system will start 6/30/2021. The program director will monitoring process and staff completion to ensure compliance. employee 16 completed the training as of 4/22/21 and proof is in their hr chart. Employee 7 shall locate and schedule the training online or in person within the next 30 days. The supervisor will monitor for compliance |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of the Staffing Requirement Facility Summary Report submitted April 16, 2021, along with an interview with the Project Director during the inspection, the facility failed to ensure that at least 50% of the employee trainings were provided by trainers not directly employed by the project for 13 out of 14 employees during the training year January 1, 2020 to December 31, 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
SOAR has contracted with a DDAP approved trainer. The trainer will be contracted to provide at least 13 hours of external trainings, per year. An ongoing training grid, maintained by HR, will track the number of internal and external training hours per year. In addition, a quarterly email will be sent to each staff member from the HR department updating them on the amount of hours completed and needed for both internal and external trainings. This system will start 6/30/2021The program director will monitor to ensure completion |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records conducted on April 27, 2021 through April 30, 2021, the facility failed to document that six of their counselors had at least 25 clock hours of training during the January 1, 2020 to December 31, 2020 training year.
Employee #3 was hired on 11/26/18 and their record showed 20 hours of training.
Employee #6 was hired on 9/8/12 and their record showed 24 hours of training.
Employee #16 was hired on 10/1/19 and their record showed 20 hours of training.
Employee #17 was hired on 12/14/15 and their record showed 24 hours of training.
Employee #18 was hired on 12/26/18 and their record showed 12 hours of training.
Employee #19 was hired on 11/28/18 and their record showed 17 hours of training.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Both internal and external trainings will be provided by SOAR. A grid will be established and maintained by the HR department. An email will be sent quarterly to each staff member from the HR department notifying them of the total number of training hours completed and total number of hours needed. This system will be in place as of 6/30/2021. The program director will monitor to ensure completion |
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 Staffing Requirement Facility Summary Report, submitted for review on April 16, 2021, the facility exceeded the FTE (full-time equivalent) of 35 active clients. Counselor #4's FTE was calculated to be 37.5.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
SOAR will continuously seek appropriate candidates for counseling positions, in order to maintain proper ratios. The Program Director will work with HR on hiring strategies, including referral bonuses, and connections with graduating college students. It is the belief that additional staff will be hired within the next 30 days (6/30/2021).The program director will monitor ratios and staff hiring ongoing to ensure compliance |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on April 27, 2021, the facility failed to keep the grounds of the facility in good repair.
The exit door located in the intake office has a hinge that is not connected at the top of the door causing difficulty opening and closing the door.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The door pump on the intake office door was fixed on 5/20/21. The maintenance department will inspect all door pumps monthly to ensure they are in proper working order. The program director will monitor to ensure completion of walk-through |
705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection conducted on April 27, 2021, the facility failed to maintain counseling areas with furnishings in good repair.
In dosing area:
office chair has green duct tape wrapped around both arms.
office chair is worn
office on left side of hallway has a chair that is worn and ripped.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/15/21, the chairs referenced will be removed. An ongoing plant walk-through will be conducted monthly, and any worn items will be removed by building maintenance. The program director will monitor to ensure completion of walk-through |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on April 27, 2021, the facility failed to have an operable exhaust fan in the client bathroom in Suite 8.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 4/30/2021, the referenced exhaust fan was fixed. An ongoing plant walk-through will be conducted monthly and any exhaust fans, which are not in good working order, will be repaired. The program director will monitor to ensure completion of walk-through |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on April 27, 2021, the facility failed to maintain the client bathroom utilized for urine collection located in the dosing area, near the nurses station. There was a hole in the wall behind the door.
This finding was reviewed with facility staff during the inspection process.
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Plan of Correction
By 6/15/21 the drywall will be repaired in the urine collection bathroom. An ongoing plant walk-through will be conducted monthly to ensure there isn't any dry wall damage. The program director will monitor to ensure completion of walk-through |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection conducted on April 27, 2021, the facility failed to ensure that the back exit out of Suite 18 was unobstructed. This exit had old chairs and office furniture stacked in the hallway which impeded exiting the building.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 4/30/2021, back exit out of Suite 18 was cleared on the day of the inspection. An ongoing plan walk through will be conducted monthly to ensure all hallways are clear. The program director will monitor to ensure completion of walk-through |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative records conducted on April 27, 2021 through April 30, 2021, the facility failed to provide an annual audit. The facility's fiscal year runs from October 1 to September 30. The document presented as the project's annual financial audit, for the fiscal year ending on September 30, 2019, was titled "Profit & Loss October 2018 - September 2019 " , however, this document did not contain the opinion of an accountant. The financial audit for fiscal year October 2019 - September 2020 was requested but was not received.
Fiscal Management has been cited in the inspections dated 8/24/2020, 10/4/2019, 1/8/2019 and 1/16/2018.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 6/30/21 SOAR CEO will identify a CPA to complete the audit. Once identified, the CEO and Board of Directors shall have an audit completed for the October 2019 to September 2020 fiscal calendar year. The audit shall be completed the private CPA by 8/30/21. The CEO will be responsible for completion |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of documents submitted on April 16, 2021, the facility failed to provide annual written individual staff performance evaluations. These evaluations were also requested of the Project Director during the licensing inspection on April 27, 2021 through April 30, 2021. Some evaluations were handed over for review, however, documentation was not presented for 7 employees. Per facility policy, annual evaluations are to be conducted upon the anniversary of the employee's hire date.
Employee #6 - hired 9/8/12
Employee #16 - hired 10/1/19
Employee # 17 - hired 12/14/15
Employee # 20 - hired 9/14/18
Employee #26 - hired 4/10/13
Employee #28 - hired 6/2/14
Employee #29 - hired 12/15/17
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All personnel annual reviews will be completed by the Supervisors. A tickler system will be instituted by 6/30/21. An email will be sent, by HR, to the Supervisor and the program director 2 weeks prior to the annual review being due. The supervisor shall completed the review and return it to the HR assistant. The HR assistant will record the receipt of the evaluation and file it in the appropriate personnel chart. The program director shall monitor the process to ensure compliance. Additionally, the reviews notes as missing will be completed by 6/30/21 by the supervisor and placed in the hr chart as proof of completion |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review client records conducted on April 27, 2021 through April 30, 2021. In 1 of 24 charts reviewed the facility failed to obtain an informed and voluntary consents that included the name of the person, agency or organization to who disclosure is made.
Client # 6 admitted 1/22/21- consent dated 1/22/21 for the PCP
consent dated 1/22/21 for the emergency contact
consent dated 1/22/21 for referring NTP
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 6/30/21 all patient consents will be electronic, and the EMR will not allow a consent to be signed without all the required information. The counselor will meet with Pt. #6 and will resign all appropriate ROI's by 6/30/21. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records on April 27, 2021 through April 30, 2021, the facility failed to obtain an informed and voluntary consent for specific information being disclosed, in one of 24 records, #15.
Client #15 was admitted on 1/30/15 - identifying information was given to an agency on 11/20/20 but the consent to release was completed 1/21/21
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 6/30/21 an internal training, conducted by the Program Director, will be completed with all Clinical Staff, within 30 days. The training will focus on the correlation between Confidentiality and ROI's. Proof of training shall be kept in the HR binders of the staff members. Ongoing, 10% of the charts shall be audited quarterly |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document that a client was offered a copy of their consent in 1 of 24 records.
Client #10 was admitted on 12/2/20 - consent dated 3/25/21 for a Lawyer
consent dated 12/2/20 for a Lab
consent dated 2/19/21 for a government agency
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 6/30/21 an internal training, conducted by the Program Director, will be completed with all Clinical Staff, within 30 days. The training will focus on the correlation between Confidentiality and ROI's. Proof of training shall be kept in the HR binders of the staff members. Ongoing, 10% of the charts shall be audited quarterly. By 6/30/21 the primary counselor will meet with patient 10 and ask them to check the box "to accept" or "not accept" a copy of the roi referenced. The clinical supervisor will review the chart to ensure completion |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records conducted on April 27, 21 through April 30, 2021, the facility failed to document notification to the client, in writing, of the decision to involuntarily terminate the client's treatment in 2 of 24 records.
Client # 2 was admitted on 12/23/19 and discharged 9/11/20 - no termination letter was found in this record.
Client # 13 was admitted on 1/31/20 and discharged 10/10/20 - the termination letter in this record is not signed or dated by client verifying client received it.
Also cited on 8/24/20 licensing inspection
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/1/21 all discharges will completed through the EMR. In order to complete the discharge in the EMR, it will not be able to be "closed" without a termination letter. Management will audit all discharges, every 30 days, to ensure compliance. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records conducted on April 27, 21 through April 30, 2021, the facility failed to provide the client with an opportunity to request reconsideration of a decision terminating treatment in 2 of 24 records.
Client # 2 was admitted on 12/23/19 and discharged 9/11/20 - no termination letter was found in this record therefore the client had no chance to request the termination of treatment be reconsidered.
Client # 13 was admitted on 1/31/20 and discharged 10/10/20 - since the termination letter in this record is not signed or dated by the client verifying receipt, documentation is not present in the record that the client was offered an opportunity to request the termination be reconsidered.
This was also cited on the 8/24/20 licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/1/21 all discharges will completed through the EMR. In order to complete the discharge in the EMR, it will not be able to "closed" without a termination letter. Management will audit all discharges, every 30 days, to ensure compliance. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of client records and unusual incident reports during the licensing inspection conducted on April 27, 2021 through April 30, 2021, the facility failed to document that the Department was notified within 3 business days that a physical assault by a client occurred on the premises on October 9, 2020.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Management will report any unusual incidents to the State, via the electronic reporting, within PA state guidelines. A print copy of the confirmation report will be printed and placed in the incidents binder, which will be maintained by the Management Team. The program director shall complete an internal training on the type of reportable incidents with all staff within the 30 days (6/30/21). Proof of training shall be kept in the hr binder. The program director shall be responsible for entering incident reports in the electronic system to monitor compliance |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of the SOAR Corp's Bi-weekly Payroll for the doctors that was conducted on April 27, 2021 through April 30,2021, the facility failed to ensure that the facility provided narcotic treatment physician services at least 1 hour per week onsite for every ten patients. These time sheets reflected that coverage was not sufficient for two weeks during the last 4 months.
12/20/20 through 12/26/20 - there were 496 active patients and 38.5 physician hours documented
12/27/20 through 1/2/21 - there were 495 active patients and 28 physician hours documented
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 4/12/21, an additional part-time MD has transitioned to full time status increasing MD time by at least 20 hours per week. The medical director will establish a rotating schedule by 6/30/2021 to cover the weeks of a holiday to ensure compliance with regulation. The CEO will oversee to ensure compliance with the plan |
715.7(a)(1-2) LICENSURE Dispensing or administering staffing
(a) A narcotic treatment program shall be staffed as follows:
(1) If it operates an automated dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 200 patients.
(2) If it operates a manual or nonautomatic dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 150 patients.
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Observations
Based on a review of the nursing time sheets submitted on April 16, 2021, the facility failed to provide documentation verifying that one full-time nurse or other person authorized by law to administer or dispense a controlled substance was available for every 200 patients to operate the automated dispensing system.
The time sheets were originally provided for the overall project, which includes 4 facilities. During the inspection, it was requested of the Project Director that only information for the current facility being licensed be submitted for review. The Project Director resubmitted the time sheets with the information from the other 3 sites removed. However, the time sheets submitted were for April 1,2020 through August 15,2020, which was reviewed during the previous licensing inspection. This inspection covers the time period of August 24, 2020 through April 30, 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/7/21, a QI assistant has been hired for the agency. The QI assistant will now shall verify the time sheets submitted for nursing hours match the comprehensive list any nurse who may have worked a shift within a time period requested, prior to submission. This verification process the system will start as of 6/30/21 |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document verification of an emergency contact in 1 of 24 records.
Client #1 was admitted on 3/3/17
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
At the time of intake, an electronic ROI will be signed by the patient for an emergency contact. Audits will be conducted by Supervisors within 14 days of admission to ensure that every patient has identified an emergency contact. The primary counselor will have client 1 sign a new ROI for an emergency contact within 30 days (6/30/21). The program director will ensure completion |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document random urinalyses at least monthly in 10 of 24 records.
Client #1 was admitted on 3/3/17 - missing February 2021 and March 2021
Client #6 was admitted on 1/22/21 - missing February 2021 and April 2021
Client #7 was admitted on 10/13/20 - missing February 2021
Client #8 was admitted on 12/23/20 - missing March 2021
Client #9 was admitted on 4/12/19 - missing March 2021
Client #12 was admitted on 9/19/11 - missing November 2020 and December 2020
Client #14 was admitted on 7/7/20, discharged 11/15/20, re-admitted 3/3/21 - missing Sept 2020 thru Nov 2020
Client #20 was admitted on 6/21/11 - missing January 2021
Client #21 was admitted on 6/6/19 - missing March 2021
Client #23 was admitted on 6/6/14 and discharged 3/25/21 - missing January 2021 and February 2021
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/1/21 Soar will no longer print out and place UDS screens into a paper chart. All UDS screenings will be downloaded into the patient's EMR file and the UDS results will be imported nightly. The Director of Nursing will monitor the imports for monthly compliance. The Director of Nursing will run a "patient without a UDS report" from the EMR twice a month and schedule testing for patients found in this manner. Process will be ongoing. |
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 24 client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document the required average amount of 2.5 psychotherapy hours per month for patient's during their first 2 years of treatment in 9 of 24 records.
Client #3 was admitted on 11/5/19 - March 2021 had 1 hour, April 2021 had 1 hour
Client #6 was admitted on 1/22/21 -April 2021 had 1 hour
Client #7 was admitted on 10/13/20 - April 2021 had 2 hours
Client #8 was admitted on 12/23/20 - January 2021 had 2 hours, February 2021 had 2 hours
Client #9 was admitted on 4/12/19 - Sept 2020 had 1 hour, Nov 2020, December 2020, Feb 2021 and March 2021 all had 2 hours each
Client #14 was admitted on 7/7/20, discharge 11/15/20, re-admitted 3/3/21 - Zero hours documented between 7/17/2020 and 11/15/2020, zero hours documented for March 2021 and April 2021
Client #19 was admitted on 3/10/21- Zero hours for March 2021
Client #21 was admitted on 6/6/19 - January 20-21 had 1 hour and April 2021 had 1 hour
Client #24 was admitted on 1/13/20 - January 2021 had 2 hours
The findings were reviewed with facility staff during the licensing inspection..
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Plan of Correction
As of 6/1/21 Soar will be using a full the EMR system to enter and track psychotherapy services. Weekly, the clinical supervisor will now run the "patients not counseled report" to identify patients who has not completed the required psychotherapy hours or hours dictated on the treatment plan. The clinical supervisor and / or counselor shall place the patient on hold for treatment completion. Continued non-compliance with treatment sessions shall be documented on the monthly service report that will be completed by the counselor. Process will be monitored by the program director |
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 client records conducted on April 27, 2021 through April 30, 2021, the facility failed to provide the required psychotherapy of 1 hour per month during the third and fourth years of treatment in 1 of 24 records.
Client #22 was admitted on 5/17/17 had zero hours documented for December 2020.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/1/21 Soar will be using a full the EMR system to enter and track psychotherapy services. Weekly, the clinical supervisor will now run the "patients not counseled report" to identify patients who has not completed the required psychotherapy hours or hours dictated on the treatment plan. The clinical supervisor and / or counselor shall place the patient on hold for treatment completion. Continued non-compliance with treatment sessions shall be documented on the monthly service report that will be completed by the counselor. Process will be monitored by the program director |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document annual physical examinations in 3 of 24 records. Per facility policy, a physical is to be conducted annually after admission.
Client #3 was admitted on 11/5/19 - missing November 2020 annual physical
Client #9 was admitted on 4/12/19 - missing April 2021 annual physical
Client #15 was admitted on 1/30/15 - missing January 2021 annual physical
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/1/21 Soar will be using a full the EMR system to enter and track all annual physical examinations. Admin staff will run the "physical report weekly" from the EMR system, and schedule any patients who are due for the annual exam. Patients missing their scheduled physicals will have this documented in a non-billable note in the EMR and shall be rescheduled. Process will be monitored by the program director |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document laboratory test results in 3 of 24 charts. Serological test results were missing from the following records:
Client #4 was admitted on 3/17/21 and discharged 4/12/21
Client #6 was admitted on 1/22/21
Client #19 was admitted on 3/10/21
This was also cited on inspection dated 8/24/20
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
a Dispensing nurse shall schedule blood work with the patient within the first 30days of admission. A nursing note will be generated in the EMR stating the scheduled appointment. Patients missing their scheduled bloodwork will have this documented in a nursing note in the EMR and shall be rescheduled. An instructional Memo shall be issued to all dispensing staff from the Director of Nursing by 6/15/2021 by email. Process will be monitored by the charge nurse for compliance |
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 client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document an annual evaluation of each patient's status, completed by the counselor and reviewed, signed and dated by the medical director. This occurred in 3 of 24 records.
Client #1 was admitted on 3/3/17 - missing March 2020 and March 2021
Client #3 was admitted on 11/5/19 - missing November 2020
Client #18 was admitted on 8/15/19 and discharged 10/8/20 - missing August 2020
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/1/21 all clinical annual evaluations shall be recorded, completed, signed and tracked in an EMR system, no longer being printed and placed within a paper chart. Weekly, the clinical supervisors will run a report within the EMR to identify clinical annual evaluations and verify with the counselor that a clinical annual evaluation was completed. At the end of each month, the Clinical Supervisors will audit clinical annual evaluations to ensure completion. |
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 conducted on April 27, 2021 through April 30, 2021, the facility failed to document a medical history within 30 days of admission, as per their policy, in 1of 24 records.
Client #20 was admitted on 6/21/11
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/1/21, SOAR shall cease the use of a paper chart and move to using an EMR. All new or updated medical history forms will be signed, completed and stored electronically in the patient's EMR file. All intake charts Stored in the EMR will be audited within 2 weeks of the admission date, by the Clinical Supervisors to ensure the medical history are seen in the system. The process will be ongoing. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document a drug and alcohol history within 30 days of admission, as per their policy, in 1of 24 records.
Client #20 was admitted on 6/21/11
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/1/21, SOAR shall cease the use of a paper chart and move to using an EMR. All new or updated all drug and alcohol history forms will be signed, completed and stored electronically in the patient's EMR file. All intake charts Stored in the EMR will be audited within 2 weeks of the admission date, by the Clinical Supervisors to ensure the all drug and alcohol history forms are seen in the system. The process will be ongoing. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document a personal history within 30 days of admission, as per their policy, in 1of 24 records.
Client #20 was admitted on 6/21/11
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/1/21, SOAR shall cease the use of a paper chart and move to using an EMR. All new or updated personal history forms will be signed, completed and stored electronically in the patient's EMR file. All intake charts Stored in the EMR will be audited within 2 weeks of the admission date, by the Clinical Supervisors to ensure the all personal history forms are seen in the system. The process will be ongoing |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document a consent to treatment upon admission, as per their policy, in 1of 24 records.
Client #4 was admitted on 3/17/21
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/1/21, all consents to treatment will be electronic at the time of admission and shall be stored in the patient's EMR file. The consents will not be able to be signed without being entirely completed including checking the box to indicate pregnant or not pregnant. The primary counselor and patient 4 will sign an updated consent to treatment within 30 days (6/30/2021) and the program director will ensure completion. |
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 a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document a psychosocial evaluation in 1of 24 records.
Client #14 was admitted on 3/3/21
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/1/21, all psychosocial evaluations, will be completed electronically, at the time of the initial assessment. All intake records will be audited, by the Clinical Supervisors within 14 days of admission to the program to ensure completion. The program director will monitor to ensure process is followed. By 7/1/21, the counselor assigned will complete a evaluation for patient # 14 within the patients EMR. the Supervisor shall monitor to ensure completion |
709.92(a) 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:
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document a comprehensive treatment plan within 30 days of admission, as per their policy, in 2 of 24 records.
Client #14 was admitted on 3/3/21
Client #19 was admitted on 3/10/21
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/1/21, all comprehensive treatment plans will be electronic. A treatment plan due report will be run, weekly, by the Clinical Supervisors and any deficiencies will be addressed with the responsible staff member. Additionally, at the end of each month, the program director will run an outstanding treatment plan report in the EMR to ensure comprehensive treatment plans are documented and signed. The process will be ongoing. the comprehensive treatment plan for chart 14 and 19 were completed on the due date but not filed at the time of the inspection. The documents are filed in the paper chart as proof of completion |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on record reviews conducted during a licensing inspection April 27, 2021 through April 30, 2021, the facility failed to document proposed support services on the comprehensive treatment plan in 1 of 24 records.
Client # 5 admitted 9/1/20
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/1/21, the treatment planning system in the EMR mandated support and the review of supports be completed in order to complete and save a treatment plan for signatures. Prior to the Clinical Supervisor signing any treatment plans, they will review all content and return the treatment plan to the counselor for any missing information. The process of placing supports and reviewing them will be ongoing |
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 conducted on April 27, 2021 through April 30, 2021, the facility failed to document treatment plans being reviewed and updated at least every 60 days in 13 of 24 records.
Client #1 was admitted on 3/3/17 - last treatment plan was dated 2/8/21, missing an update for 4/8/21
Client #5 was admitted on 9/1/20 - treatment plan's dated 10/1/20 and 2/1/21, missing an update for 12/1/20
Client #6 was admitted on 1/22/21- last treatment plan dated 2/22/21, missing an update for 4/22/21
Client #7 was admitted on 10/13/20 - March treatment update due 3/12/21, was completed on 3/14/21. Additionally, the 1/12/21 treatment plan was missing the date the client signed this treatment plan.
Client #11 was admitted on 7/2/14 -had a treatment plan dated 8/2/20 and 11/7/20, missing an update for 10/2/20. Additionally, the 12/2/20 treatment plan was missing the date of completion by the counselor and this plan repeated the previous goals but did not explain why this was done.
Client #12 was admitted on 9/19/11 -treatment plans dated 9/17/20 and 1/19/21, missing an update for 11/17/20
Client #13 was admitted on 1/31/20 -last treatment plan dated 7/1/20, missing an update for 9/1/20
Client #15 was admitted on 1/30/15 -had treatment plans dated 12/20/20. The 2/20/20 treatment plan was completed late, on 3/3/21.
Client #17 was admitted on 9/29/20 -last treatment plan dated 10/29/20, missing an update for 12/29/20
Client #18 was admitted on 8/15/19 -last treatment plan dated 7/15/20, missing an update for 9/15/20
Client #20 was admitted on 6/21/11 -last treatment plan dated 2/12/21, missing an update for 4/12/21
Client #22 was admitted on 5/17/17 -last treatment plan dated 2/25/21, missing an update for 4/25/21
Client #24 was admitted on 1/13/20 -last treatment plan dated 2/13/21, missing an update for 4/13/21
This was also cited on inspection dated 8/24/20.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/1/21, all treatment plans will be electronically developed, signed and store in the patient's EMR record. Treatment plans will no longer be printed, signed or stored in a paper record. To track due dates, a treatment plan due report will be run, weekly, by the Clinical Supervisors and any deficiencies will be addressed with the responsible staff member. Additionally, at the end of each month, the program director will run an outstanding treatment plan report in the EMR to ensure treatment plans are documented and signed. The process will be ongoing for files cited:
patient 1 update was completed on 4/8 but not filed at review, currently filed
patient 6 update was completed on 4/22 but not filed in chart currently filed
patient 20 update was completed on 4/12 but not filed in chart currently filed
patient 22 update was completed on 4/25 but not filed in chart currently filed
patient 24 update was completed on 4/13 but not filed in chart currently filed
patient 7 will be asked to resign and date the 1/12/21 treatment plan with the current date signed to resolve the missing signature date by 6/30/2021 supervisor to ensure completion
patient 11 counselor unable to add signature date to 12/2/20 treatment plan as they no longer employed at facility.
patient 13 and 17 information for treatment plan referenced can not be obtained due to being discharged |
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 conducted on April 27, 2021 through April 30, 2021, the facility failed to assure that counseling services were provided according to the individual treatment plan. Per the Project Director, groups have not been conducted since March 2020 due to COVID -19 and what he saw as potential confidentiality issues using a video or call in platform. However, there continued to be documentation on treatment plans that clients were to attend groups in 10 of 24 records.
Client #1 was admitted on 3/7/17 - treatment plans dated 10/8/20, 12/8/20 and 2/8/21
Client #2 was admitted on 12/23/19 and discharged 9/11/20 - treatment plan dated 9/2/20
Client #4 was admitted on 3/17/21 and discharged 4/12/21 - treatment plan dated 3/17/21
Client #5 was admitted on 9/1/20 - treatment plans dated 9/1/20, 10/1/20 and 4/1/20
Client #6 was admitted on 1/22/21 - treatment plans dated 1/22/21 and 2/22/21
Client #12 was admitted on 9/19/11- treatment plans dated 9/17/20, 1/19/21, 2/19/21 and 4/19/21
Client #19 was admitted on 3/10/21 - treatment plan dated 3/10/21
Client #20 was admitted on 6/21/11 - treatment plans dated 10/12/20, 12/12/20 and 2/12/20
Client #21 was admitted on 6/6/19 - treatment plans dated 11/6/20, 1/6/21 and 3/6/21
Client #24 was admitted on 1/13/20 - treatment plans dated 10/13/20,12/13/20 and 2/13/20
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 6/15/21 staff will receive an instructional memo from the program director about how to appropriately document counseling services, which are being provided according to the individual treatment plan, and that accurately depict the services rendered. The Clinical Supervisors will review the treatment plans in the EMR record prior to ensure treatment services are documented correctly on the plans. |
709.93(a)(1) 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:
(1) Consent forms.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document updated consent to release forms in 5 of 24 records.
Client #9 - consent forms were not updated since 2019, however, the form states that updates are to be done annually. Government agency (2), family contact (1), funding source (3) and lab (3).
Client #11- consents to be updated annually but last signed in 2015 include Government agency (2), emergency contact (1), funding source (3). Consent for lab expired 1/22/21.
Client #12 - consent for lab expired 1/16/21
Client #15 - releases were not updated annually, per the form. This includes 2 consents for government agencies, 2 consents for funding sources, a consent for a lab and a consent for the emergency contact. Also, the facility supplied an agency with client information on 11/20/20, however, the consent to release for that agency was not completed until 1/21/21.
Client #17 - this record contained two letters with identifying client information, dated 11/3/20 and 3/3/21, made out to "to Whom It May Concern". Consent for these letters can't be verified.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 6/30/21 all patient consents will be electronic, and the EMR will not allow consent to be signed without all the required information. The counselor will meet with Pt. #6 and will resign all appropriate ROI's by 6/30/21. The clinical supervisor will monitor to ensure completion |
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 the review of client records conducted on April 27, 21 through April 30, 2021, the facility failed to document a record of services provided to the client monthly in 6 of 24 records.
Client #4 was admitted on 3/17/21 and discharged 4/12/21 - missing March 2021.
Client #13 was admitted on 1/31/20 and discharge 10/10/20 - missing August 2020, September 2020 and October 2020
Client #14 was admitted on 7/7/20 and discharged 11/15/20, re-admitted 3/3/21 - missing August 2020, September 2020, October 2020, November 2020 and April 2021
Client #21 was admitted on 6/6/19 - missing December 2020
Client #22 was admitted on 5/17/17 - missing November 2020 and December 2020
Client #23 was admitted on 6/6/14 and discharged 3/25/21 - missing March 2021
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/1/21 the client service records will be in the electronic medical record and will no longer be required to be printed and placed in a paperwork record. The service record shall be sorted with the patient's EMR and can be viewed at any time. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on a review of the client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document progress notes in 3 of 24 charts.
Client #4 - This record was missing a progress note for an individual session held on 4/1/21, per the April 2021 record of service.
Client #13 - The last progress note was dated 8/18/20, however, the last record of service documented was for July 2020. Therefore, this progress note can't be verified.
Client #22- This record was missing a progress note for an individual session held on 4/21/21, per the April 2021 record of service.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/1/21 the client service records will be in the electronic medical record and will no longer be required to be printed and placed in a paperwork record. As of 6/1/21 the client progress notes will be generated signed and stored in the electronic medical record and will no longer be required to be printed and placed in a paperwork record. The service and progress notes will be viewable at any time. Ongoing, the Quality Assurance Assistant and Clinical Supervisor will monitor the process by completing the missing signature report and unfinished note report in the EMR |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document case consultations in 5 of 24 charts.
Client #1's last case consultation was documented on 9/3/19.
Client #6 was admitted on 1/22/21 and the first one was to be completed by 4/22/21. As of the date of the inspection the case consultation was missing.
Client #7 was admitted on 10/13/20 -case consultation dated 4/13/21 is missing the date the clinical supervisor signed.
Client #12's case consultation dated 8/20/20 reflects the counselor and the clinical supervisor signed on different dates. The counselor signed on 8/20/20 and the clinical supervisor signed on 8/29/20.
Client #16 was admitted on 7/14/17 and discharged 9/5/20 and the last documented case consultation was documented on 8/1/19. The yearly case consultation was to be completed by 8/1/20.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 6/1/21 all case consults will be electronic. The Management team will be able to audit charts monthly and address deficiencies with each counselor. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document aftercare plans that were individualized to the client. The plans are the same for every client and they are signed by the client on their admission date.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 6/30/21, all aftercare plans will be done during intake, then updated annually. The clinical supervisors will be responsible for ensuring the reviews are completed as such. The program director will complete an in-house training on the aftercare plans and the need to individualize them by 6/17/21. Proof of training will be stored in the employee record |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to show when the discharge summary was completed in 1 of 24 charts. Discharge summaries are the be completed within 7 days of the client's discharge date.
Client #2 was admitted on 12/23/19 and discharged 9/11/20 - discharge summary was not signed or dated by staff
This finding was reviewed with facility staff during licensing process.
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Plan of Correction
As of 6/1/21, all discharges will be completed electronic medical record of the patient. The electronic medical record will not allow the discharge summery to be completed without the beige signed or dated. Management will audit discharges monthly to ensure the discharge summaries are in compliance |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records conducted on April 27, 2021 through April 30, 2021, the facility failed to document follow- up's after discharge in 5 client records. Per the facilities P&P the first follow-up is to occur 30 days after discharge. The following follow-ups were completed on 3/17/21.
Client #2 was discharged on 9/11/20
Client #13 was discharged on 10/10/20
Client #14 was discharged on 11/15/20
Client #16 was discharged on 9/5/20
Client #18 was discharged on 10/8/20
This was also cited on inspection dated 8/24/20.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
At the end of each month a discharge report will be run a supervisor and the administrative staff will send follow up letters. Staff will copy the envelope and letter for verification of being sent. The program director will follow up to ensure process is completed. the system is in place as of 6/1/2021 |