INITIAL COMMENTS
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This report is a result of a complaint investigation and an on-site licensure renewal inspection conducted on January 8, 2019 through January 10, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the complaint investigation and an 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records of 12 counselors January 8 - 10, 2019, the facility failed to ensure that each counselor met the qualifications for the position in 1 of 12 records reviewed. Employee # 20 hired on December 26, 2018 had a BS in Psychology/Counseling; however lacked the required one year's experience per the regulations.
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Plan of Correction
The employee referenced has a confirmed Masters degree from an accredited university La Salle University majoring in Professional clinical counseling. The employee referenced had a documented internship and practicum associated with the completed degree for over 1 year at the time of hire. Final confirmation of the Master degree earned posted on the national student clearing house on 1/15/19 and was hired on 12/26/18. To resolve the issues, Soar shall take the following actions. First the counselor will sign a new job description from the date of hire of 12/26/18 to the education verification date of 1/15/19 that states an assistant counselor status. The counselor will then sign a new job description from the education verification date of 1/15/19 to present that will reflect the full counselor status. These steps shall be completed by 4/30/19 by the Human Resource Director. Moving forward, the Human Resource Director shall be checked by the project director to ensure compliance with the applicable regulations |
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 20 personnel records and the Staffing Requirement Facility Summary Report Form completed by the facility on January 9, 2019, the facility failed to provide documentation of individual training plans for the 2019 training year in 20 of 20 records reviewed. Personnel/training records were reviewed on January 8 -10, 2019. The facility failed to document individual training plans for the January 1 - December 31, 2019 training year in 20 records reviewed.Per the Staffing Requirement Facility Summary Report Form completed by the facility on January 9, 2019, the facility documented that individualized training plans were developed for the Project Director, Facility Director, 2 Clinical Supervisors, 17 counselors and/or counselor assistants and 6 support staff on January 1, 2019. The facility was closed on January 1, 2019.
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Plan of Correction
At the time of the inspection the 2019 training plans were completed but not filed. The training plans were completed by the clinical supervisor and human resource directors as of 1/3/19. Moving forward, to ensure the plans are completed and entered in the HR files of each employee by January1 of each year, all training plans shall be completed and entered in the employee files by December 31st of each year. The clinical supervisor shall ensure the completion of the plans and human resource director shall ensure that the plans are filed within the employee file. The project Director shall ensure the completion of this plan |
705.21 (3) LICENSURE General req. for nonresidential facilities.
705.21. General requirements for nonresidential facilities.
The nonresidential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
Based on physical plant inspections conducted on January 8-10, 2019, the facility failed to comply with applicable Federal, State and local laws and ordinances.The facility failed to comply with applicable Federal, State and local laws and ordinances as there were items (rugs and furniture) in the exit passageway leading to the fenced areas which was in violation of the posted signs from the local Fire Marshall.
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Plan of Correction
As Soar occupies a multi-tenant building, other tenants may at times deposit items which can impede egress from the building in case of an emergency. As of 2/1/19, the building owner's staff has removed all furniture and rugs that were in the hallways from other tenants. Moving forward, the landlord has agreed to inspect the exit passageways on a weekly basis to ensure unobstructed egress. In addition Soar will also conduct visual inspections on a monthly basis. Currently egress is unobstructed. The project Director is be responsible |
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on physical plant inspections conducted on January 8 - 10, 2019, the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety. The fence was leaning and broken around the facility in several places.Additionally, a facility must be suitable for the purpose, appropriately equipped and meet all the requirements of this act and of the applicable statutes, ordinances and regulations, in order to maintain a license. The facility has insufficient space inside for the clients waiting to be dosed and/or attend counseling. Clients are expected to wait outside of the facility in varying types of weather. These clients may be medically fragile or have medical conditions that could be exacerbated in these circumstances. While an awning was provided, the awning is insufficient to accommodate the number of clients forced to wait outside. Additionally, there are no sides to protect these clients from the cold, or from blowing precipitation. There is also no heating or cooling source available to these clients in the extreme cold or hot weather. 62 P.S. 1007 (Issuance of license)
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Plan of Correction
The fence referenced has been maintained on a regular basis by Soar and the landlord. Despite this, the fence was found to be in disrepair on a frequent basis. Consequently, Soar's Project Director hired a independent contractor on 3/1/19 to remove the fence. The fence has been completely removed as of 4/1/19.
Soar has allowed clients who may be medically fragile or have medical conditions to have unrestricted access to the lobby. Client who are waiting for dosing and counseling sessions often sit this lobby are that has served clients for over 10 years. Many clients who are waiting for group therapy often choose to wait outside of the facility to be able to smoke, eat or drink as these activities are not allowed within the facility. Nonetheless, Soar has added additional waiting area in the rear of the building and also in suite one in order to meet the needs of clients during high volume time periods. The additional areas have been added by the project director as of 1/14/19 and the project director shall monitor needs for further 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 physical plant inspections conducted on January 8-10, 2019, the facility failed to maintain the grounds of the facility in a clean, safe, sanitary manner and in good repair at all times for the safety and well being of clients, employees and visitors. The following deficiencies were noted at the time of the inspection:1. The exterior on the Left side of the building was not free from trash as the side of the building was loaded with garbage and dangerous trash that appeared to have been present for some time. 2. The parking lot had big pot holes that were unsafe for anyone walking from their car.3. There were syringe needles found throughout the grounds of the facility.4. During the physical plant inspection it was observed that the pressure relief valve on the water heater was not properly installed as it failed to include a diversion pipe that would direct hot water within six inches from the floor or below the floor, as per the safety instructions printed on the water heater. There was corrosion around the pressure relief valve where it had been leaking water. Due to the lack of a diversion tube for the pressure relief valve, the potential for discharged water to make contact with live electrical parts would be likely since the upper heating element is located to the left and below the pressure relief valve.
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Plan of Correction
1. As of 4/15/19, The landlord is responsible for maintaining the building exterior and grounds. In an effort to keep up with trash generated by illegal dumping and other factors, the landlord has agreed to inspect and clean those areas on almost a daily basis. Additionally Soar will conduct visual inspections on a weekly basis. The Project Director shall be responsible to ensure that this occurs.
2. The potholes observed by DDAP were repaired in early December 2018, but reoccurred due to weather conditions and extensive daily traffic. All potholes have been repaired as of 4/15/19. Moving forward Soar will conduct visual inspections on a weekly basis to ensure safety of the people walking to the main entrance. The Project Director shall be responsible to ensure that repairs and inspections occur.
3. Soar staff has never observed syringe needles throughout the grounds including at the time of the inspection. Consequently there was no need for corrective actions to be taken. Nonetheless, inspection of the premises including the parking lot areas will be completed on a weekly basis by the Program Director or designee. The program director shall ensure completion
4. A HVAC contractor has inspected the water heater and replaced the pressure release valve and installed a diversion pipe as of 4/15/19. A HVAC contractor shall inspection all water heaters annually. The Project Director shall ensure the completion.
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on physical plant inspections conducted on January 8-10, 2019, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents. The dumpsters were overflowing with garbage and trash. The dumpers were not covered and there was trash and garbage piled up around and behind the dumpster into the parking lot.
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Plan of Correction
Soar occupies a multi-tenant building with the dumpster being located approximately 100 feet from the main entrance. Due to our urban location, there have been numerous illegal dumping of trash at this site. Although the dumpster was full at the time of initial inspection, DDAP staff observed trash being picked up during the time of the inspection. It was suggested by a DDAP inspector that an additional private locking dumpster be purchased by Soar which would place Soar in compliance. However, this would not resolve the trash accumulation at the existing dumpster. Consequently, the landlord has agreed to increase the rate of trash pickups and Program Director will complete weekly inspection of the trash site. This system was put into place as of 4/1/19 and the project director shall ensure compliance |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on physical plant inspections conducted on January 8-10, 2019, the facility failed to ensure privacy so that counseling sessions could not be seen or heard outside the counseling room. 1. The group room second floor lacked window treatment.2. Counseling Offices and Group rooms had transfer grills in the doors and/or walls allowing sessions to be heard outside the rooms.3. One group room had a camera that broadcast to the receptionist desk and to select facility staff smart phones. 4. One Group room had a wall that stopped short at an exterior wall where there was a window allowing for the session to be heard and seen.
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Plan of Correction
1. Although the group room windows did not all contain window treatments, the room is located on the second floor at the corner of the building and as such identification of any individuals in that room is not readily achievable without the use of such extreme measure of binoculars and telescopes. Nonetheless, As of 4/29/19, the contractor hired by the project director has the window treatments installed in the spirit of cooperation. The project Director shall ensure continued compliance with this regulation.
2. Specifically on some doors, a one by one square at the bottom of the door with an air transfer grill. These doors were in place for many years and never cited in prior inspections. As a routine measure there were white sound machines outside the doors. Soar feels the citation is an unreasonable and over-reaching interpretation of the regulations. Consequently Soar feels that this regulation should be removed. Nonetheless, Soar contractor hired by the project director has installed wood panel on the interior of the door as of 4/1/19.The project Director shall ensure continued compliance with this regulation.
3. The camera referenced was removed on the date of the inspection by a Soar contractor. The project Director shall ensure continued compliance with this regulation.
4. The configuration of the wall at the corner has been like that since 2008 and never cited during prior inspections. There is a 2 INCH gap from one corner of the wall to another. Soar feels the citation is an unreasonable and over-reaching interpretation of the regulations. Consequently Soar feels that this regulation should be removed. Nonetheless, a Soar contractor hired by the Project Director has closed the gap in the wall as of 4/1/19. The project Director shall ensure continued compliance with this regulation.
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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 physical plant inspections conducted on January 8-10, 2019, the facility failed to maintain each bathroom in a functional manner at all times.During the inspection two of the facility bathrooms located in the administration/counseling area of the building had sinks that were falling and pulling away from the wall.
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Plan of Correction
Soar has installed floor standing vanities in order to address the disrepair arising from frequent use as of 4/1/19. The Program Director will inspect all bathrooms on a weekly basis. The project Director shall ensure continued compliance with this regulation.
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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 physical plant inspections conducted on January 8-10, 2019, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.The facility failed to ensure fire safety. The exit passageway discharged to a fenced in uneven earthen area with no gate for exiting the area. Additionally, the exterior door was unable to be opened fully due to the landscape timbers shifting and impeding the opening of the door.
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Plan of Correction
As of 4/3/19, the fence noted blocking the exit passageway has been removed. The Landscape timbers noted as impeding the opening of a door have been removed. Currently a clear walkway to exit is present without an obstruction. The program Director shall conduct weekly inspectors of all emergency exit doors to ensure unobstructed egress. The project Director shall ensure continued compliance with this regulation.
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on physical plant inspections conducted on January 8-10, 2019, the facility failed to ensure that fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The facility had a fire extinguisher in the elevator equipment room that had not been inspected since 2016.
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Plan of Correction
The one fire extinguisher referenced has been inspected and updated as of 4/15/19. Soar fire inspector alert one shall continue their annual inspection and updating of fire extinguishers. the program Director shall ensure no fire extinguishers are omitted by alert one. The Project Director shall ensure compliance with this regulation. |
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 the facility's administrative documents on January 9, 2019, the facility failed to have documented an annual audit for their fiscal year January 2017 - December 2017.
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Plan of Correction
Soar Corp's CEO will request that the Board of Directors approve an authorization for an audit to be completed for the Oct 1, 2017 to Sept 30th 2018 time period. The request for the audit shall be made at the next board meeting in 30 days. The CEO will be responsible in facilitating and arranging for an independent auditor within the next 90 days. Proof of completion shall be supplied as needed to the regional project director to meet the standard. Ongoing the CEO will make request for the approval of an auditor annually in the first quarter of each year and shall supply a copy to the Regional Project Director. |
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 personnel records January 8 - 10, 2019, six of which required written individual staff performance evaluations, the facility failed to ensure that there were current signed performance reviews in three of six records reviewed.Employee # 1 serving as PD since January 4, 2015, had no signed performance review in the file since the performance review completed April 20, 2017.Employee # 2 serving as FD since January 25, 2016, had no signed performance review in the file since the performance review completed December 22, 2015.Employee # 7 hired on September 24, 2015 as a file clerk and promoted to the position of counselor on September 12, 2017 had no Performance review in the file since the performance review completed October 13, 2016.
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Plan of Correction
Soar shall APPEAL Employee 2 and 7
Employee 1 was completed late and has been completed as of 3/6/19 and is in the employees chart.
Employee 2 the statements within the citations are incorrect. Annual evaluations are present for 12/22/15, 12/22/16, and 12/22/17 and were in the employees chart. As of 3/6/19, employee 2 annual reviews due on 12/22/18, has been completed. To address the two late reviews, The Human Resource Director shall create an employee grid to track the due dates of all annual and semi-annual employee reviews by (6/1/19). HR Director will be responsible to check the employee grid on a weekly basis to identify upcoming employee reviews. The HR Director shall notify the Program Director and Site Supervisor by e-mail 2 weeks prior to the due date for the evaluation. The Program Director and Site Supervisor will complete the evaluation with the employee by the due date and submit it to the HR Director. The HR Director will then update the tracking date for the next review on the employee grid This will be an ongoing check and balance system to ensure time of completion. The two employee charts cited have been corrected and the reviews have been placed in their HR charts as of 3/6/19.
Employee 7 statements on the employee's dates are inaccurate and disputed. Employee 7 was hired on 9/24/15 as stated but resigned as of June 28, 2017. Based on the resignation, a 9/24/17 performance review that is being cited as missing would not have been completed, as the employee referenced was no longer an employee. The resignation letter was in the employees HR chart as the time of the onsite inspection. The employee was rehired at Soar Corp on September 12, 2017 as a counselor, making this her new HIRE DATE and the new Anniversary date for the annual performance review. The 2018 performance review based on the new hire date and annual review date of 9/12/17 is present in the employee chart.
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on physical plant inspections conducted on January 8-10, 2019, the facility failed to secure hard copy client records within locked storage containers. 1. There were two rooms/storage closets in the administrative/counseling area that had been left unlocked and had file folders containing client records. One room/storage closet had in them approximately 200 folders piled on the floor and one had approximately 200 folders on the shelves and floor.2. There was a closet with sliding doors, having no locking mechanism that had file folders with client records, and binders with client group sign in sheets listing the full names of the clients. This closet was in the hallway of the second floor counseling area located above the main security area.
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Plan of Correction
As of 4/1/19, the storage room doors containing the client records have had automatic keypad locks installed on the doors that lock automatically upon closing. The auto lock handle will prevent the action of being left unlocked accidently by a staff member entering the room. Ongoing all future storage rooms with patient records shall have this type of lock installed to prevent occurrence. As of 4/1/19, the closet cited has had any patient information stored in it removed and returned to the chart room. Within 30 days (5/1/19), this closet on the 2nd floor will be deleted by replacing it with a solid wall to remove any ability to items to be stored. |
709.28 (c) 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.
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Observations
Based on a review of client records on January 9-10, 2019, the facility failed to obtain a valid consent to release in 22 client records.The facility exceeded 4 PA Code 255.5 by allowing the insurance companies to receive demographic information on the client.Client #1 - two consent - 7/18/18.Client #2 - two consents - 1/5/18Client #3 - two consents - 12/28/17Client #4 - two consents - 10/6/17Client #5 - two consents - 4/16/18Client #6 - two consents - 1/23/18Client #7 - two consents - 7/10/17Client #10 - two consents - 10/11/17Client #11 - two consents - 11/19/18Client #12 - two consents - 8/17/18Client #13 - two consents - 5/1/18Client #14 - two consents - 6/20/18Client #18 - one consent to the client's parole officer - 1/13/18Client #17 - two consents - 1/31/18Client #20 - two consents - 5/22/17Client #21 - two consents - 10/23/18Client #22 - two consents - 6/14/17Client #23 - two consents - 11/11/15Client #24 - two consents - 6/22/18Client #25 - two consents - 2/21/18Client #26 - two consents - 5/30/18Client #27 - two consents - 12/20/17Additionally;Client #2 - First, two faxes were sent to a provider, but no consent to releases on file for that provider. Faxes went out 1/5/18 and 1/8/18. Second, two consents one dated 1/5/18 for a treatment provider and another dated 10/5/18 for an agency did not have the purpose documented on those consents. Lastly, a consent to agency failed to have the staff's signature/date and whether the client was offered a copy of the consent.Client #5 - A consent for a lab signed by the client on 10/11/18 but failed to have staff's signature and date on the consent form.Client #6 - Two faxes sent to a clinic was sent on 1/23/18 and 1/24/18 and the facility failed to have a consent to release on file for the clinic.Client #14 - A consent for a lab was signed on 10/10/18, but a urine sample was sent to this lab on 9/20/18 without a consent from the lab.Client #23 - All consent documented expired on 11/11/16, no updated consent to releases as of the date of the inspection.
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Plan of Correction
part 1: SOAR'S Release of information being cited was reviewed BY DDAP during a onsite inspection on 2/22/19, and was approved for use by a DDAP Supervisor with the word "Demographic" meaning a social security number and DOB that are required for payment and treatment authorization on the release for a insurance company. DDAP reviewed the ROI's in question as part of our initial licensing inspection of the Warminster Site in December of 2018, and approved the ROI for use as part of the initial licensing review. Finally after reviewing the last 5 annual reviews at all Soar sites, DDAP has never cited the "demographic "within the last 5 annual reviews of the program.
As of 5/19/19, The Regional Project Director shall remove the word demographic from the Soar releases for an insurance carrier. By 5/31/19, the program director shall have clients 1-27 noted in the findings sign new releases for their insurance carrier that does not state demographic. The program director shall ensure that these revised releases shall be placed in the patient records by 5/31/19
Part 2--- The Program Director will hold training on confidentiality and proper release formulation within the next 30 days (5/19/19). The training will be mandatory for all clinical and intake staff. The training will cover the 255.5 regulation, and release completion including proper signatures and properly indicating release forms with the name of the person, agency or organization to which disclosure is to be made. Training certificates shall be kept in the HR binder of each employee to serve as proof of training. Post training, The Program director and Clinical supervisor shall complete audits monthly on 10% of the charts to identify and issues with ROI's. If an issue is noted the clinical supervisor shall return the chart to the counselor for correction and it will be documented in a supervisor meeting. The audit process shall be ongoing.
The program Director shall be responsible to correct the consent forms where possible for patients #2, 5, 6, and 23 by 5/19/19. Program Director will ensure compliance through weekly audits.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of the facility's client rights form and the facility's client handbook, the facility failed to include the above verbiage.
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Plan of Correction
Soar has reviewed the patient handbook and rights and has concluded that the necessary language is contained within the documents. The statement is on page 2 under #18. Additionally this language is found within the patient handbook on page 6 under #18. Finally, the statement is posted within the clients rights advertised on the Soar Webpage and in the downloadable copy of the patient's rights from the website. However in the spirit of cooperation The Regional Project Director will revise the patient right form and handwork reframing the sentence in question to read "A client receiving care or treatment under section 7 of the act (71 P. S. 16900.107) shall retain civil rights and liverties except as provided by statue. No client may be deprived of a civil right solely by reason of treatment". This revision shall be completed by the regional director by 5/19/19
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records on January 9-10, 2019, the facility failed to notify DDAP within 3 business days of the unusual incident.While reviewing client #4's progress notes, the note dated 9/23/18 had documentation that ambulance personnel was called at the facility for the client.
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Plan of Correction
The Program Director shall offer internal refresher training on reporting incident report by 5/1/19 to all clinical and nursing staff. Instruction for reporting the incident report shall be discussed, that includes but is not limited to notification of the medical director, program director and report completion. The program director will have the sole responsibility to file, fax and to notify DDAP within the required time period for the unusual incident. The Program Director shall complete the incident report cited and fax it to DDAP by 5/1/19. The project Director shall ensure compliance with this regulation |
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 nursing hours for the months of December 2018 and January until the 8th of 2019, the facility failed to ensure that the facility has one full-time nurse or person authorized by law to administer or dispense a controlled substance for every 200 patients. The facility currently has a census of 481.On December 29, 2018 the facility only had one nurse on duty who worked a total of 6.45 hours. On December 30, 2018 the facility had two nurses working, one nurse worked a total of 7hrs and the other nurse worked 4.5hrs.
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Plan of Correction
On 12/29/18, the facility had a total of 2 nurses on duty who worked a total of 6.45 hours each. The third nurse scheduled call out due to a sickness On 12/30/18 the facility had a total of 3 nurses on duty one for 7 hrs, one for 4.5hrs and one for 6.45 hours. Time sheets were supplied to verify claim. Soar has no way of verifying whether or not this was an oversight by DDAP staff or that Soar did not provide the timesheets in question at time of inspection. As of 1/10/19, The Human Resource Director shall continue supply time sheets as requested or directed by DDAP during all further on site inspections the Human Resource Director shall monitor for compliance |
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 on January 9-10, 2019, the facility failed to ensure a urinalysis is completed monthly in client record #5.Client #5 was admitted on 4/16/18. The urinalysis was missing for the month of September 2018.
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Plan of Correction
---SOAR SHALL APPEAL THIS FINDING---
Client record #5 by the inspection key did have a completed UDS screen for the month of September 2018. As a result, Soar did ensure a urinalysis is completed monthly in client record #5. The Proof of the UDS screen completion was supplied to DDAP. Soar's Clinical supervisors will continue ongoing chart audits to identify any missing service rendered reports, clinical documentation, billable notes and UDS reports. Any missing or incomplete documentation found in the process shall be address by the clinical supervisor and placed within the chart
Soar has no way of verifying whether or not this was an oversight by DDAP staff or that Soar did not provide the UDS result in question at time of inspection. It is contained within the chart at the present time. Soar can only conclude that it was contained in the chart at the time of inspection.
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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 client records on January 9-10, 2018, the facility failed to ensure that the patient receives at least 2.5 hours of psychotherapy which shall include 1 hour for individual sessions.Client #2 was admitted on 1/5/18 and during the month of December 2018 the facility failed to document an individual session.Client #27 was admitted on 10/20/17 and discharged on 3/26/18. There was no documentation of an individual or group sessions for the month of February 2018.
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Plan of Correction
The patient 27 was in prison during the month of February, therefore Soar was unable to complete an individual counseling session with the patient. It is documented within a medical and nursing note that on 2/5/18 Soar nursing department was contacted by the Philadelphia Prison system for a last dose verification and confirmed the patient's prison status. An excused absence entered on 2/5/18 for 60 days due to prison status and the patient was discharged in March due to extend sentence. Documentation can be supplied to verify. Soar feels that the required documentation was contained within the patient record and that an additional progress note would be redundant.
However in the spirit of cooperation with DDAP's request, the regional Director shall instruct all clinical staff to place secondary documentation in a client's record in the form of a non-billable progress note to reflect patients excused status due to jail or hospitalization after it is already documented by the medical staff. The instructional memo shall be sent from the regional director to all staff by e-mail by 5/10/19 and the procedure shall be effective as of 5/10/19. The e-mail shall serve as confirmation of notice. The program director shall monitor for completion
PATIENT 2--Soar acknowledges no individual session in that month. To resolve issue, Soar's clinical supervisors shall run the "patient not counseled report" within Tower 2 weeks prior to the close of a month to identify patients who have not completed the minimum standard of at least 2.5 hours of psychotherapy that includes 1 hour for individual sessions. The clinical supervisor shall print out the list by caseload and review with the counselors. The counselors will place the patients on hold to complete the sessions prior to the close of the month. This system will be effective as of 5/1/19
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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 client records on January 9-10, 2019, the facility failed to notify the transferring facility of the client's initial dose in client record, #12.Client #12 was admitted on 8/17/18.
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Plan of Correction
Soar shall complete a internal training on the transfer in and transfer out procedure including the dose verification by 5/24/19. Training will be completed with all clinical and intake staff of the facility. Intake staff shall fax the notification of initial dose on the date of intake. Chart audit to be completed by Clinical supervisor or Director within 1 week of admission date to ensure completion. Processing shall be ongoing |
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 on January 9-10, 2019, the facility failed to ensure that the facility completes an annual physical reevaluation of the client in client record, # 2 and 3.Client #2 was admitted on 1/5/18 and their initial physical took place on 1/5/18.Client #3 was admitted on 12/28/17 and their initial physical took place in December 2017.
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Plan of Correction
Patient 2--documented that the annual physical was done on Friday, 1/4/19 by the MD, the Physical was in the process of being filed at the time of the unannounced inspection on 1/8/19.
Soar strives to file documents within 3 business days from the date of origination. the chart was inspected 2 business days following the creation of document. The document was available as it is customary of DDAP staff to request documents that they can not find within the chart
Patient 3--it is documented that the patient purposely missed her scheduled annual physical and attempts to manage the patients non-compliance with the physical were made. Physical was completed on 1/17/19. Soar will continue to reschedule missed physical appointments by patients to remain in 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 on January 9-10, 2019, the facility failed to ensure that the facility completes an annual evaluation of the client in client record, # 2 and 3.Client #2 was admitted on 1/5/18 and their initial evaluation took place on 1/5/18.
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Plan of Correction
Patient 2 it is documented that the annual clinical evaluation was done on, 1/5/19 by the counselor and staff involves. The document was not filed in the patients chart over the weekend was in the process of being filed at the time of the unannounced inspection on 1/8/19.
Patient 3 it is documented that the annual clinical evaluation was done on Friday, 12/28/18 by the counselor and staff involve. The document was not filed in the patients chart over the weekend and holiday was in the process of being filed at the time of the unannounced inspection on 1/8/19. Soar was in compliance with completing the annual evaluation in both cases.
Soar strives to file documents within 3 business days from the date of origination. The chart was inspected 2 business days following the creation of document. The document was available as it is customary of DDAP staff to request documents that they cannot find within the chart. Program director will monitor for timely filing within the guidelines stated above
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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 on January 9-10, 2019, the facility failed to evaluate the client when it comes to the client readiness for treatment, asset/strengths, mental status, support services and a clinical evaluation of the client in client records, #1, 2, 5, 6, 12, 13, 17 and 26. Client #1 - 7/31/18Client #2 - 1/29/18Client #5 - 5/16/18Client #6 - 2/22/18Client #12 - client was admitted on August 17, 2018 and as of the date of the licensing inspection there was no documentation of a psychosocial evaluation.Client #13 - June 1, 2018Client #17 - January 1, 2018Client #26 - 5/30/18
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Plan of Correction
The program director of the facility shall complete an internal training on the proper completion of a psychosocial evaluation within 30 days. The training shall cover methods to improve the content and documentation within each of the 13 domains on the psychosocial evaluation that includes the readiness to change, strengths, support services, mental health and others. Proof of completion shall be kept in the counselor's HR file. Post training the clinical supervisor shall review each submitted evaluation from a counselor to approve content or suggest corrections. The clinical supervisor shall document the corrections needed in a supervision note and the time period for corrections. Client 12's eval shall be completed by the Program Director by 5/19/19. Program Director will ensure compliance through weekly audits. |
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 on January 9-10, 2019, the facility failed to document a comprehensive treatment plan in 4 of 18 client records.Client #11 was admitted on 11/29/18 Client #12 was admitted on August 17, 2018Client #20 was admitted on 5/22/17 and the comprehensive treatment plan was completed until 8/6/17.Client #27 was admitted on 10/20/17 and discharged on 3/16/18
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Plan of Correction
By 5/19/19, a excel data base chart check grid that highlights all due documentation within one week of the date will be developed program director and regional director. The excel data base will show and highlight all of the due dates for treatment plans, case conferences, and annuals. The excel data base will be stored within a network folder that is viewable to all counseling staff and supervisors, allowing staff to review and track daily. During the supervision sessions, the chart check grid shall be reviewed by the supervisor, approved completed treatment plans will be logged on the grid and due dates for treatment plans will be updated on the excel grid by the supervisor. . During the session, the Supervisor will establish a deadline for any outstanding work with the counselor. The supervisor will document the plan in the supervision note with the counselor. The system will start to be used as of 5/19/19, and will provide up to date tracking. The clinical supervisor shall be responsible for the management of the system of this system. Additionally, during periods of counselor transition, the clinical supervisor shall take the responsibility for managing the caseload and completing treatment plans on time with the patient during the transition period. Client 11 and 12's treatment plans shall be completed by the Program Director by 5/19/19. Program Director will ensure compliance through weekly audits. |
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 on January 9-10, 2019, the facility failed to document treatment plan updates as required in 7 of 21 records reviewed.Client #1's comprehensive treatment plan was completed on 8/18/18. No treatment plan updates documented after the completion of the comprehensive treatment plan.Client #4 's last treatment plan update was documented on 12/18/18.Client #8's last treatment plan was documented on 11/14/17, client transferred to another facility on 3/19/18.Client #13's last treatment plan update was documented on 8/1/18, client transferred to another facility on 10/30/18.Client #14's comprehensive treatment plan was completed on 7/20/18 and the treatment plan update wasn't completed until 11/20/18.Client #20's last treatment plan was documented on 8/22/18.Client #24's comprehensive treatment plan was completed on 7/22/18 and the client was discharged on 10/30/18.
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Plan of Correction
By 5/19/19, a excel data base chart check grid that highlights all due documentation within one week of the date will be developed program director and regional director. The excel data base will show and highlight all of the due dates for treatment plans, case conferences, and annuals. The excel data base will be stored within a network folder that is viewable to all counseling staff and supervisors, allowing staff to review and track daily. During the supervision sessions, the chart check grid shall be reviewed by the supervisor, approved completed treatment plans will be logged on the grid and due dates for treatment plans will be updated on the excel grid by the supervisor. During the session, the Supervisor will establish a deadline for any outstanding work with the counselor. The supervisor will document the plan in the supervision note with the counselor. The system will start to be used as of 5/19/19, and will provide up to date tracking. The clinical supervisor shall be responsible for the management of the system of this system. Additionally, during periods of counselor transition, the clinical supervisor shall take the responsibility for managing the caseload and completing treatment plans on time with the patient during the transition period Client 1, 4 and 20 treatment plans shall be completed by the Program Director by 5/19/19. Program Director will ensure compliance through weekly audits. |
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 on January 9-10, 2019, the facility failed to provide counseling per the client's treatment plan in three client records.Client #5's comprehensive treatment plan and treatment plan updates states that the client is to receive individual sessions (1x a week) and group sessions (1x a week). During the months of June, July, September and November 2018, the client was only seen three times each month and in May 2018 was only seen twice for individual sessions. Additionally, for the months of August 2018 only seen three times and November 2018 seen twice for group sessions. Client #14 - The facility's Treatment Agreement states "all patients in the outpatient level of care shall attend a minimum of one individual session and one three-hour group per week through their course of treatment. The client's record showed an individual session occurring on October 10, 2018 and the next individual session occurring November 18, 2018. In addition, an individual session occurred on August 2, 2018 with the next session occurring on August on August 29, 2018. Client #15's treatment plan dated January 29, 2018 states individual treatment plans (1x a week). In the client's record, an individual note was recorded by the client's counselor on February 15, 2018. The note stated that due to the counselor covering a group session, the client's individual session will be rescheduled for the following week.
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Plan of Correction
Soar continues to hold treatment standards in excess of the state minimum requirements of 2.5 hours of therapy a month and shall continue to expect patients to attend a weekly individual and group therapy sessions. These standards are stated within the patient handbook, signed by the patient as a treatment agreement at intake and are noted on the signed patient treatment plans as stated in the report. Soar encourages patients to follow their treatment agreements and plans but patients at times elect to not follow their signed agreements or a emergency arises that causes a session to be rescheduled. To document a patient's decision to not follow an agreement or plan Soar will do the following. First Soar will increase treatment plan non-compliance documentation by additional non-billable notes for all missed individual sessions and will continue to document staffing of treatment plan non-compliance by the use of a case conference note. Second, Soar will continue to document a staff absence or need to reschedule an appointment as cited in patient 15 to justify a schedule change. Soar has no intentions of decreasing its treatment expectations, shall continue to make efforts to help patients follow their signed treatment agreements and shall continue to document deviations from the agreement |
709.93(a) 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:
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Observations
Based on a review of client records on January 9-10, 2019, the facility failed to document a complete client record in records, 14 of 27 records reviewed.Client #1 was admitted on July 18, 2018. The facility failed to document a case consultation as of the inspection.Individual progress note dated 8/26/18 had the signature of the counselor as 8/6/18. Additionally, there were no counselor assessment for the following individual notes dated 10/23/18, 10/30/18 and 11/6/18. Lastly, the following group notes had the same clinical assessment verbiage "PIR appeared to be stable with normal affect congruent with mood as indicated by being attentive and focused during the entire lecture. PIR arrived on time to group and was appropriately dressed for age range and weather. PIR is in the stage of maintenance. (verbal and facial expression)", #11/6/18, 10/30/18, 10/16/18, 10/2/18, 9/18/18, 9/11/18, 9/4/18, 8/28/18, 8/21/18 and 8/14/18.Client #2 was admitted in January 5, 2018.The case consultation was completed on 10/5/18, but only included the counselor, no other staff involved. Additionally, there were no individual sessions documented for December 2018.Client #8 was admitted on 8/4/16 and discharged on 3/19/18. The follow-up form dated 4/18/18 did not show that a follow-up was completed, only had the name of the client and staff signature/date. The check boxes showing the follow-up wasn't checked verifying a follow-up.The last case consultation was documented on 1/4/17.Client #9 was admitted on 8/5/15 and discharged on 1/11/18.The follow-up form dated 2/10/18 did not show that a follow-up was completed, only had the name of the client and staff signature/date. The check boxes showing the follow-up wasn't checked verifying a follow-up.Client #10 was admitted on 10/11/17 and discharged on 5/30/18.The follow-up form dated 6/29/18 did not show that a follow-up was completed, only had the name of the client and staff signature/date. The check boxes showing the follow-up wasn't checked verifying a follow-up.Client #13 was admitted on 5/1/18 and discharged on 10/30/18. There was no documentation of the client's record of service, a case consultation or a follow-up attempt. Client #15 was admitted on 6/29/16 and discharged on 4/4/18.There was no documentation of a case consultation, or a follow-up attempt and the last documentation of a record of service was 10/31/16. Lastly, the client's discharge summary and client information report provided by the facility to the inspection team stated client's discharge was completed and satisfactory. Additionally, information provided in the discharge summary and the client's record, showed the client transferred to another facility for non-compliance.Client #16 was admitted on 11/2/17 and discharged on 2/20/18. There was no documentation of a record of service or a follow-up attempt.Client #17 was admitted on 1/31/18 and discharged on 3/12/18. There was no documentation of a record of service, case consultation or a follow-up attempt.Client #18 was admitted on 11/8/17 and discharged on 2/14/18. There was no documentation of a record of service or a follow-up attempt.Client #23 was admitted on 11/11/15. The following individual progress notes were all identical, #8/17/18, 8/31/18 and 9/6/18 which included the data, assessment and plan.Client #24 was admitted on 6/22/18 and discharged on 10/30/18. There was no documentation of a follow-up attempt.Client #25 was admitted on 2/21/18 and discharged on 5/9/18. There was no documentation of a follow-up attempt.Client #27 was admitted on 10/20/17 and discharged on 3/26/18. The following progress notes were documented on the client's record of service, but no note provided for reviewed, 1/25/18 (individual) and 1/29/18 (group).
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Plan of Correction
1 As of 5/1/19, Soar Corp will have a member of its medical records team print out the electronic client record of service from Tower systems for the previous month for all current patients. The printed client record of service shall be placed in the client's paper chart record. The previous month's record of service shall be in the chart by the 15th of each month. Also by 6/1/19, Soar Corp will have a clinical supervisor complete a close out audit on all discharges from the program within 30 days of the discharge date. The close out audit will identify any missing service rendered reports, clinical documentation, billable notes and review the discharge summery. Any missing or incomplete documentation found in the process shall be address by the clinical supervisor prior to placing the discharge chart in storing. The close out audits shall be ongoing.
2. In addition, to address content issues within billable notes, Soar Corp will have a formal training on DAP note formulation to all clinical staff within the next 60 days (6/1/19). The training will cover the content, clinical assessment and data points for all individual and group notes. Proof of training shall be placed within the staff members HR binder. Ongoing, each clinical supervisor shall review with the counselor a sample of at least 5 individual progress notes and 5 group notes within a monthly supervision session
3. Finally, the follow up letters cited in the report "did not show that a follow-up was completed, only had the name of the client and staff signature/date. The check boxes showing the follow-up wasn't checked verifying a follow-up" are copies of the follow up letters sent to the patient by mail. The instructions on the follow up form state to the patient receiving the survey to "Please take the following brief survey and send it back to SOAR in the provided envelope." As of 5/1/19, Soar will start to photocopy the addressed envelope with the stamp and attached it to the patient's follow up letter that is signed by a staff member. This will serve as further proof the outreach attempt was made to a patient to complete a follow up form and return it to Soar. Soar has no means to control if a follow up is completed or returned to the facility by a patient as this is a choice of the patient to do so. Client 1 case conference has been completed as of 4/24/19 by the primary counselor and program director.Program Director will ensure compliance through weekly audits.
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