INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 13, 2024 through August 14, 2024 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 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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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the narcotic treatment program failed to maintain onsite a photograph of each patient, which is to include the patient's name and date of birth, in one of eight patient records reviewed.
Patient #7 was admitted on October 28, 2023 and was discharged on December 6, 2023. There was no documentation of a photograph of the patient in the client record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The patient referenced will have an updated photo identification with their name and birth date loaded into the EMR by 10/1/2024. The program director will be responsible for ensuring it is complete. Ongoing, a member of the QI department will audit all new admissions within 30 days of the admit day to ensure a photo with the name and dob is found. Any occurrence of a missing photo with be reported to the program director for correction. The audit process will begin 10/1/24 be ongoing. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure the narcotic treatment physician determined the initial dose of the patient in three of three applicable patient records reviewed.
Patient #5 was admitted on October 27, 2023 and was discharged on July 2, 2024. The initial methadone dose was determined and ordered on October 27, 2023; however, the determination and order was completed by a certified registered nurse practitioner and not a narcotic treatment physician.
Patient #6 was admitted on November 9, 2023 and was discharged on December 24, 2023. The initial methadone dose was determined and ordered on November 9, 2023; however, the determination and order was completed by a certified registered nurse practitioner and not a narcotic treatment physician.
Patient #7 was admitted on October 18, 2023 and was discharged on December 6, 2023. The initial methadone dose was determined and ordered on October 18, 2023; however, the determination and order was completed by a certified registered nurse practitioner and not a narcotic treatment physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The regional project director shall issue a written memo to the medical team of the corporation by email regarding regulation 715.7c. The memo will state that at the time of admission, the initial methadone dose must determine and ordered by a MD only. the memo will also state that a CRNP and P.A. who have a Mid-Level exemption are not authorized by the regulation to set an initial dose order but are allowed to adjust dosing orders and issue take home dosing for patients. The memo will be issued by 10/1/24. the QI department will audit all new admissions within 30 days of the admit day to ensure the memo is followed. Occurrence of the memo not being followed will be reported to the medical director for correction. The audit process will begin 10/1/24 be ongoing. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files, which is to include the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and the current status of the patient, in one of two applicable patient records reviewed.
Patient #6 was admitted on November 9, 2023 and was transferred out on December 24, 2023. There was no documentation in the record indicating that the program transferred the required materials to the receiving narcotic treatment program.
This is a repeat citation from the September 27, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Vendor of the EMR system has developed a new system in the electronic patient file to document a transfer request. All transfer outs will now be documented electronically, and shall include the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and the current status of the patient When a patient makes a transfer request, the primary counselor will send an email to the program director with 24 hours of the request. The counselor will complete the transfer documents in the emr system, sending the required documents to the outside provider within 7 days of the request. To ensure completion, the program director will audit the patient chart upon receiving a notification of transfer to ensure the documentation is complete. Occurrences of missing or incomplete document will be addressed by the program director for correction a instruction memo explaining process will be issued by 9/19/2024 by email from the regional director and he system will be used as of 9/19/2024. |
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 and the date of the initial dose given to a received patient in one of two applicable patient records reviewed.
Patient #5 was admitted on October 27, 2023 and was transferred out on July 2, 2024. There was no documentation, in the record, indicating the program notified the receiving narcotic treatment program in writing of the patient ' s admission date into the program and the date of the initial dose given to the patient.
This is a repeat citation from the November 8, 2022 and September 27, 2023 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Vendor of the EMR system has developed a new system in the electronic patient file to document a transfer request All transfer in's will now be recorded and documented electronically, and shall include the initial dosing information, last dose information, admission date, dosing records. When a patient makes transfers in, the intake counselor will send an email to the program director with 24 hours of the request. The counselor will complete the transfer in documents in the emr system, sending the required documents to the outside provider within 24 hours of the admission date. To ensure completion, the program director will audit the patient chart upon receiving a notification of a transfer in to ensure the documentation is complete. Occurrences of missing or incomplete document will be addressed by the program director for correction a instruction memo explaining process will be issued by 9/19/2024 by email from the regional director and he system will be used as of 9/19/2024 |
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 narcotic treatment program failed to ensure counselors completed an annual evaluation of the patient's status, which is also to be reviewed, dated, and signed by the medical director, in three of five applicable patient records reviewed.
Patient #3 was admitted on May 3, 2023 and was active at the time of the inspection. An annual evaluation of the patient's status was due to be completed no later than May 3, 2024; however, there was no annual evaluation documented in the record at the time of the inspection.
Patient #4 was admitted on May 2, 2021 and was active at the time of the inspection. An annual evaluation of the patient's status was completed on May 30, 2023, and the next annual evaluation was due no later than May 30, 2024; however, there was no annual evaluation documented in the record at the time of the inspection.
Patient #8 was admitted on April 12, 2019 and was discharged on June 28, 2024. An annual evaluation of the patient's status was completed on April 12, 2023, and the next annual evaluation was due no later than April 12, 2024; however, there was no annual evaluation documented in the record prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new audit report within the EMR system. The audit report number 151e entitled Annual review /Assessments by caseload will identify any annual review that is overdue or upcoming within a specified time period of the report. As of 9/9/2024, a directive has been sent by email to the clinical supervisors and program directors stating that the rep 151e report must be completed ever two weeks to identify overdue or upcoming annuals. Occurrences of missing or incomplete documents will be addressed by the program director. Corrections to the documents will be completed and given to the program director within 1 week. This process will start as of 9/9/24 and shall be ongoing. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on review of the program's unusual incident reports, the narcotic treatment program failed to notify the Department within 48 hours of a death or serious injury due to trauma, suicide, medication error or unusual circumstances.
The program was notified of the off-site death of a patient on March 28, 2024; however, the program did not report it to the Department until July 30, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The regional Director has issued a instructional memo to the newer management teams of the program regarding the critical incident report system. The memo outlines the types of incidents that need to be reported, and the expected time periods for reporting the incidents. The memo reviewed the procedure to reporting the incident. As of 9/9/24 the program director of the facility is responsible for filing all incident reports. Ongoing, on a monthly basis, the regional director will complete a audit to ensure all incidents are report, occurrences of missing report will be issued to the program director for correction. The monthly checks will begin at the end of September of 2024 and 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, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in four of eight client records reviewed.
Client #1 was admitted on October 9, 2020 and was active at the time of the inspection. A treatment plan update was completed on April 19, 2024, and the next update was due no later than June 19, 2024; however, the update was not completed as of the date of the inspection.
Client #2 was admitted on December 21, 2016 and was active at the time of the inspection. A treatment plan update was completed on May 9, 2024, and the next update was due no later than July 9, 2024; however, the update was not completed as of the date of the inspection.
Client #4 was admitted on March 2, 2021 and was active at the time of the inspection. A treatment plan update was completed on January 17, 2024, and the next update was due no later than March 17, 2024; however, the update was not completed as of the date of the inspection.
Client #5 was admitted on October 27, 2023 and was discharged on July 2, 2024. A treatment plan update was completed on January 26, 2024, and the next update was due no later than March 26, 2024; however, the update was completed on April 9, 2024. Additionally, the next treatment plan update was due no later than June 9, 2024; however, the update was completed on July 3, 2024.
This is a repeat citation from the November 8, 2022 and September 27, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
audit reports within the EMR system will be used weekly to treatment planning. The audit report number 147D entitled Treatment plans due in a date range will identify any overdue or upcoming tx plans within a specified time period of the report. As of 9/9/2024, a directive has been sent by email to the clinical supervisors and program directors stating that the rep 147d report must be completed ever weekly to identify overdue or upcoming treatment plans. Occurrences of missing or incomplete documents will be addressed by the assigned clinical supervisor of the counselor. Corrections to the documents will be completed and given to the clinical supervisor within 1 week. The weekly verification of due dates will begin as of 9/9/24 and be monitored by the program director for completion |
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, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in two of three applicable client records reviewed.
Client #6 was admitted on November 9, 2023 and was discharged on December 24, 2023. There was no follow-up information documented in the record at the time of the inspection.
Client #7 was admitted on October 18, 2023 and was discharged on December 6, 2023. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The QI department will run the discharge follow up report weekly in the emr system to identify missing or incomplete follow ups. Once identified, the QI department will send a report to the clinical staff by email. The clinical supervisor will discuss outstanding follow ups in the supervision sessions. The process will be monitored by the QI department to ensure completion. The process of completing the weekly audit report will begin as of 10/1/2024 and be ongoing.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing treatment plan updates within the regulatory timeframe was submitted and approved by the Department for the November 8, 2022 and September 27, 2023 annual licensing inspections. Not completing treatment plan updates within the regulatory timeframe was again found to be a deficiency in the August 13, 2024 through August 14, 2024, annual licensing inspections.
A plan of correction for documenting that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given was submitted and approved by the Department for the November 8, 2022 and September 27, 2023 annual licensing inspections. Not documenting that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given was again found to be a deficiency in the August 13, 2024 through August 14, 2024, annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The regional project director has recommended seeking out and hiring a QI Manager for the agency to the board of directors and CEO of the corporation. The QI Manager will be responsible to for auditing and following up on the plans of correction issued in order to ensure compliance is met. The approval and hiring process for the position should be completed by 12/1/2024
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