INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection, conducted on December 22 - 23, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corp. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a written semiannual performance evaluation in one of one record reviewedThe findings include:One counselor assistant personnel record was reviewed on December 22, 2015. The facility failed to provide a written semiannual performance evaluation for employee # 5.Employee # 5 was hired as a counselor assistant on April 6, 2015. The semiannual performance evaluation was to be completed by October 6, 2015. The facility failed to provide or document a semiannual performance evaluation based upon measurable performance standards for employee # 5 as of the time of inspection.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/13/16, the Regional Director has met with the supervisory staff of Soar and completed an education session to properly supervise and document the supervision of the assistant counselor. On 1/14/16, the Regional Director issued an instructional memo to the supervisor Soar that outlines the supervisory documentation for an assistant counselor. This memo was sent via e-mail to all of the supervisors and the e-mail shall serve as the receipt of notification. To ensure, the semiannual reviews are completed, The HR director shall now monitor the due dates of the semiannual reviews and shall send a reminder via email to the immediate supervisor. The Supervisor shall complete and then turn the review into the HR Director. The HR director shall report to the Program Director if there are any issues of a supervisor not completing the review and this will be address by the program director in their supervision session with the clinical supervisor. This check and balance system will be ongoing. The employee who is missing their semiannual review is scheduled to meet with the Regional Director on 1/19/16. This review shall be completed then and place in their HR file on 1/19/16 |
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 personnel records, the facility failed to ensure that each counselor assistant documented to the facility director that they were working toward counselor status.The findings include:On December 22, 2015, one counselor assistant personnel record was reviewed to ensure they were working toward counselor status. The facility failed to ensure employee # 9 was working toward counselor status. Employee # 9 has a Bachelor's degree in Business Administration Marketing. The Bachelor's degree does not meet the educational requirements for the position of counselor; thus employee # 9 was required to provide annual documentation that he was working toward counselor status.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/4/16, the Regional Project Director has met with the assistant counselor and an official written plan has been established stating how the employee is working towards the counselor status. The written plan has been signed by the Regional Project Director and by the employee. A copy of the plan has been placed in the HR binder of the employee. The direct supervisor of the employee will document the progress towards the counselor status in the supervision notes. The documentation shall be kept in the HR binder of the employee. To ensure this deficiency does not recur, The HR Director will send a reminder of the need to submit documentation to all assistant counselors requesting documentation showing the work towards the counselor status to the supervisors and counselor in the beginning of December. The Human Resource Director will receive documentation from the counselor assistant upon the completion of each calendar year. The documentation shall be kept in the HR binder of the employee. The facility director will follow up with the HR Director to ensure a counselor assistant has completed the documentation |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facilities work schedule and copies of staff CPR and First Aid cards, the facility failed to ensure that CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills was onsite during the project's hours of operation.The findings include:Facility days of operation and hours: Monday - Friday 6 AM - 4 PM Saturday & Sunday 6 AM - 2:30 PMDispensing days and hours: Monday - Friday 6 AM - 4 PM Saturday & Sunday 6 AM - 1:00 PMBased on the work schedule and CPR and First Aid cards provided by the facility on December 22, 2015, the facility failed to provide CPR and First Aid coverage on Saturday & Sunday from 1 PM until 2:30 PM. The facility has nursing staff on duty; however, they only work until 1 PM on Saturday & Sunday. The facility was unable to provide any additional documentation verifying that non-nursing staff would work beyond 1 PM were trained in CPR and First Aid coverage on Saturday & Sunday from 1 PM until 2:30 PM. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/5/16, The Regional Director has located a outside trainer From Jefferson Health Systems to provide both CPR and First Aid training for all staff. The trainer has been contacted and all of the clinical and admin staff shall receive this training at the site within the next 60 days (3/15/16). Documentation of completion shall be kept in the employees HR binder and will be documented as a external training on the annual training log. To ensure this deficiency does not recur, SOAR'S current health and safety committee will include monitoring CPR and First Aid Certification into its inspections. Quarterly the committee will make a assessment of the shift needs for CPR and First Aid and place their recommendations for certification and training in Health and safety quarterly report. If training is indicated, the regional Director shall have the training scheduled for the stated shift. In addition, Soar shall have at least one Supervisor and two counselors on staff from 1 pm to 2:30 pm on Saturday and Sunday to ensure appropriate CPR and First Aid is available. this shall be a ongoing process to ensure 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 personnel records and a review of the Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that at least one-half of all training 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 in one of one record reviewed.The findings include:One personnel training file and the SRFSR were reviewed on December 22, 2015. The facility provided documentation showing that more than half of the facility's training's were provided in-house by facility staff. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The HR Director develop a excel training log grid listing all employees by 1/31/16. New hires shall be added to the sheet at the time of hire by the HR Director. Training hours completed shall be logged onto this sheet and also the employee annual training sheet. The training log will differentiate if the training is internal or external. HR Director and Regional Director shall audit quarterly the training hours to ensure the hours record in the HR file match the hour's record on the training grid. Additionally, on a monthly basis, the HR Director shall send a email to each individual counselor informing them of the documented training hours on file. This email will state the number of internal or external hours that need to be obtained in order to be in compliance. The e-mail notification shall be copied to the immediate supervisor of the counselor. The immediate supervisor shall discuss with the counselor their training hours, document the discussion and be responsible to ensure the training hours are met. The monitoring process will be ongoing |
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 and a review of the Staffing Requirements Facility Summary Report form, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training.The findings include: Four personnel records were reviewed on December 22, 2015. The facility's training year was from January 1, 2014 through December 31, 2014. The facility failed to ensure two out of four employees, # 10 and 11 completed at least 25 clock hours of annual training.Employee # 10 was hired July 8, 2013, and was required to complete 25 hours of annual training. Employee # 10's training file included documentation of 22 training hours.Employee # 11 was hired December 19, 2013, and was required to complete 25 hours of annual training. Employee # 11's training file included documentation of 10 training hours.In addition, the Staffing Requirements Facility Summary Report form which was finalized by the facility on December 22, 2015 documented less than 25 clock hours of training for employees #10 and 11.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The HR Director develop a excel training log grid listing all employees by 1/31/16. New hires shall be added to the sheet at the time of hire by the HR Director. Training hours completed shall be logged onto this sheet and also the employee annual training sheet. The training log will differentiate if the training is internal or external. HR Director and Regional Director shall audit quarterly the training hours to ensure the hours record in the HR file match the hour's record on the training grid. Additionally, on a monthly basis, the HR Director shall send a email to each individual counselor informing them of the documented training hours on file. This email will state the number of internal or external hours that need to be obtained in order to be in compliance. The e-mail notification shall be copied to the immediate supervisor of the counselor. The immediate supervisor shall discuss with the counselor their training hours, document the discussion and be responsible to ensure the training hours are met. The monitoring process will be ongoing |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to provide hot water. The findings include:A physical plant inspection was conducted on December 23, 2015. The facility failed to provide hot water in the bathrooms located in Suite 1.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/13/16, the Regional Director as had a outside contractor inspect and complete a estimate for the repairs outlined in the report. The Regional Director has now authorized the repairs mentioned in the report and it is expected that all repairs shall be completed by 1/22/16. The Regional Director and V.P> shall monitor the repairs being completed by the contractor and complete a final inspection on 1/22/16 to ensure the work is complete. To ensure this deficiency does not recur, SOAR'S current health and safety committee will start to complete monthly inspections of the building and property. The inspections shall be documented, and repairs shall be submitted to the regional director on a monthly basis. This will be an ongoing process. |
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, the facility failed to ventilate bathrooms by exhaust fan or window. The findings include:A physical plant inspection was conducted on December 23, 2015. The facility failed to ventilate bathrooms by exhaust fan or window in the following suites:Suite 1 - The exhaust fans in the bathrooms were not operable at the time of inspection. Suite 2 - The exhaust fan was not operable in one out of three bathrooms inspected.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/13/16, the Regional Director as had a outside contractor inspect and complete a estimate for the repairs outlined in the report. The Regional Director has now authorized the repairs mentioned in the report and it is expected that all repairs shall be completed by 1/22/16. The Regional Director and V.P. shall monitor the repairs being completed by the contractor and complete a final inspection on 1/22/16 to ensure the work is complete. To ensure this deficiency does not recur, SOAR'S current health and safety committee will start to complete monthly inspections of the building and property. The inspections shall be documented, and repairs shall be submitted to the regional director on a monthly basis. This will be an ongoing process. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail.The findings include:A physical plant inspection was conducted on December 23, 2015. The facility failed to ensure that the steps located at the rear of the facility had a well-secured handrail. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/13/16, the Regional Director as had a outside contractor inspect and complete a estimate for the repairs outlined in the report. The Regional Director has now authorized the repair to place in a handrail as mentioned in the report and it is expected that all repairs shall be completed by 1/22/16. The Regional Director and V.P. shall monitor the repairs being completed by the contractor and complete a final inspection on 1/22/16 to ensure the work is complete. To ensure this deficiency does not recur, SOAR'S current health and safety committee will start to complete monthly inspections of the building and property. The inspections shall be documented, and repairs shall be submitted to the regional director on a monthly basis. This will be an ongoing process. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection, the facility failed to ensure interior exits were lit at all times.The findings include:A physical plant inspection was conducted on December 23, 2015. The facility's second floor emergency exit was not lit at the time of the inspection. Additionally, the emergency exit in Suite 1 was not lit and the crawl space exit was in total darkness. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/13/16, the Regional Director as had a outside contractor inspect and complete a estimate for the repairs outlined in the report. The Regional Director has now authorized the repairs to have the light bulbs replaced in the emergency hallways as mentioned in the report and it is expected that all repairs shall be completed by 1/22/16. The Regional Director and V.P. shall monitor the repairs being completed by the contractor and complete a final inspection on 1/22/16 to ensure the work is complete. To ensure this deficiency does not recur, SOAR'S current health and safety committee will start to complete monthly inspections of the building and property. The inspections shall be documented, and repairs shall be submitted to the regional director on a monthly basis. This will be an ongoing process. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the facility failed to obtain the services of independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The findings include:The facility's administrative documentation, specifically the financial audit, was reviewed on December 22, 2015. The document presented as the project's annual financial audit was titled, "Financial Statements." However, the document did not contain all the required elements of a financial audit, including the opinion of the accountant and the use of generally accepted accounting principles. The findings were reviewed with facility staff during the licensing inspection.This is a repeat deficiency. The facility was previously cited for non-compliance on November 22, 2013 and December 11, 2014.
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Plan of Correction
SOAR CORP'S Vice President of Operations shall retain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug and alcohol services. Soar shall have an official audit for 1/1/2014 to 12/31/2014 completed by the May 1, 2016. The Vice President shall have the audit firm supply more than the financial summary report that was issued for this inspection. SOAR CORP'S Vice President of Operations shall be responsible for ensuring the annual audit of financial activities is completed on an annual basis by the end of the second quarter (June), for the previous calendar year. SOAR CORP'S Vice President of Operations shall report the completion of this audit to the Soar Board who will act as a secondary check and balance to ensure completion. |