INITIAL COMMENTS
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This report is a result of a follow-up licensure renewal inspection conducted on September 23, 2019 through September 27, 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
The facility failed to document that a counselor had the required qualification for the position.Employee #20 was hired as a counselor on 7/9/19 with a World Education Services degree equivalence documenting of a bachelor's degree in Business Administration which is not a qualifying degree for the position of counselor.This information was reviewed with the facility staff during the licensing inspection.Gregg Hummel 10/02/19
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Plan of Correction
As of 10/24 2019, the employee's status was be changed to a title of assistant counselor and a training plan will be established for the position change. Employee 20 will file an application for a CADC certification within the next 6 months of his status change (5/1/2020), and provide proof to Human Resources. Employee 20 agreed to seek full certification of a CADC by 11/1/2020. Moving forward, Human Resources will refer to DDAP list of approved degrees to verify the potential employee's degree as a qualifying degree for the position of counselor. A second verification shall be completed by the Regional Project Director prior to hire. The 2 step verification shall be ongoing. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Employee #5 was hired as a counselor on 9/4/18. The HIV/AIDS training was due to be completed by 9/4/19 but was not documented at the time of the inspection.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Employee five is scheduled to complete the training reference on 11/13/19. Limited offerings of a training that meets the Department approved curriculum resulted in the delay. Human Resources shall monitor employee five for completion and place the training certificate in the file upon completion. Ongoing, Human Resources will continue to assist new staff in completing trainings to meet the state regulations within the allowable time frame. |
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 September 26, 2019, the facility failed to maintain all structures on the grounds of the facility to be free from any danger to health and safety. The fence from the rear of the building around to the south side was leaning and in poor condition in several places.This information was shared with the facility staff.Gregg Hummel 10/04/19
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Plan of Correction
The fence being cited on the rear south side of the building is not owned by Soar and is part of the property not frequented by the clients. It is part of the neighboring business and was installed by the neighboring business. However in the spirit of cooperation, Soar had the section of fence in reference fixed during the onsite inspection at the request of the DDAP inspectors. The DDAP inspectors took pictures as proof of the completed repair. Ongoing Soar will not be responsible for maintaining structures, fences, and completing repairs to exterior grounds considered to be the property of the neighboring businesses. |
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
The facility failed to keep the grounds of the facility safe and in good repair.The sidewalk from the rear sidewalk to the main building was broken and, several large pot holes were discovered in the parking lot adjacent to the sidewalk next to the front of the facility which created a trip hazard.Additionally, there were two discarded syringes found on the lawn next to the sidewalk directly in front of the building near the fire exit and the water heater in suite #2 was identified in the corrective action plan as having been repaired as of 4/15/19 however this repair was not completed at the time of the inspection.Gregg Hummel 9/30/19
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Plan of Correction
1. Soar repaired cracks in the rear sidewalk during the onsite inspection at the request of the DDAP inspectors. The DDAP inspectors took pictures as proof of completion. It is Soar's opinion that the cracks were level and minor in nature and did not represent a tripping hazard. 2. The potholes mentioned in the report were filled during the onsite inspection at the request of the DDAP inspector. The DDAP inspectors took pictures as proof. Subsequently, since the inspection, the parking area has been marked with signage indicating the responsible owner for maintaining the parking areas. Going forward any potholes that are observed to be on the dosing side of the property or in a parking area of our building owner shall be maintained by Soar. Staff shall report a pothole in these areas to the program director and the repair will be authorized by the regional project director. Soar will not be responsible for parking areas marked being owned by another entity. Repairs shall be ongoing. 3. All water heaters had the check valve were replaced by a licensed plumber to meet the previous plan of correction and no further repairs were noted by the plumber to ensure the proper installation of the heaters in question. As of 10/28/19, a diversion pipe will be added to the heater to comply with DDAP. Pictures will be available upon request 4. In regards to the discarded syringes they were found in the bushes and not readily visible. Please note the grounds are sometimes frequent by the homeless during off hours which may lead to an occasional discarded syringe. Soar's staff and the property owner continue to be diligent in the property clean up but cannot guarantee that the property will not be free of a syringe at all times. Soar staff will continue daily sweeps and clean up of our area to ensure the property is maintained, clean and safe for its staff and patients of the program. |
705.22 (3) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(3) Keep exterior exits, stairs and walkways lighted at night if in use.
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Observations
The facility failed to keep the walkways lighted when in use.The facility dosing hours are from 6 am to 2 pm. DDAP staff arrived at the facility at 05:55 am; the conditions prior to sunrise were pitch black. There were no lights on around the perimeter of the building or the parking area adjacent to the building despite the presence of clients outside the building and arriving for services. Facility staff indicated that the lights are timed to come on at 05:00 am.This information was shared with the facility staff.
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Plan of Correction
The timer for the walkway light was corrected on the day of the inspection. Subsequently, the timer has been replaced with a new unit by the building owner. Daily, staff that arrive while it is dark, will monitor the lighting and notify the regional project director if they are not on when they should be. Weekly, the building owner will have his staff check the timer and lights to ensure they are operational and shall address issues as needed. Process shall be ongoing |
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
The facility failed to ensure that all refuse was stored in containers and that refuse containers were covered.The dumpster at the lower end of the parking area outside the facility entrance was uncovered; the right side of the cover was missing. Additionally there were two partially filled plastic trash bags sitting next to the sidewalk in front of the building. Gregg Hummel 10/04/19
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Plan of Correction
As stated in the prior plan of correction, Soar cannot control the illegal dumping that happens overnight and around the parking lot prior to the start of business hours. The dumpster in question continues to be shared with many businesses within the building and we cannot control their practices of closing lids and placing trash in the container. Nonetheless, Soar obtained its own locking dumpster on 10/17/19 for use. Soar will use its independent dumpster for its facility and will no longer use or be responsible for the community dumpster. Soar will have its staff ensure trash at its own dumpster is place in the container, the lids are closed and the locking mechanism is in place to prevent dumping in our container. Daily, the program director and clinical supervisors shall complete checks at the start of their shift and ongoing of the grounds and sidewalks to ensure any trash bags left on a sidewalk are placed in the dumpster. The checks will start as of 11/5/19 and shall be ongoing |
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 September 24-26, 2019, the facility failed to ensure the privacy of counseling sessions. A group session was in process in the first floor suite; the window in the group room, adjacent to the interior lobby of the building, had a window covering that was not covering the entire window allowing direct visual access to the group session.This information was reviewed with the facility staff during the licensing inspection.Gregg Hummel 10/02/19
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Plan of Correction
Per the DDAP reviewers during the exit interview of the onsite inspection, the blind in question was observed left pulled open 6 inches from the bottom of the window for over two minutes before staff alerted the clinician conducting the group who pulled the blind down The window treatment referenced window was fully installed and in good condition. To ensure compliance with the regulation, the regional project director shall send an instructional memo to all clinical staff by e-mail by 11/8/19. The instructional memo shall state the clinician is responsible to ensure all blinds are closed completely at the beginning of group, during group and the close of a group session. The memo shall state that the clinician is responsible to redirect a patient who opens a blind. Supervisors shall observe the group rooms and clinicians daily to ensure compliance |
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
The facility plan of correction for this deficiency indicated that the audit would be authorized "at the next board meeting in 30 days"; however, according to the facility staff, the next board meeting did not occur until July 3, 2019, therefore no audit has been completed for the October 1, 2017- September 30, 2018 fiscal year.Gregg Hummel 10/1/19
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Plan of Correction
Soar did obtain board approval at the next scheduled board meeting for the audit that happened within 60 days instead of 30 days in the previous poc. Soar is in the process of scheduling the October 1, 2017- September 30, 2018 fiscal year audit.The audit shall be scheduled by the CEO within the next 45 days (12/23/19)and the CEO shall be responsible to ensure the scheduled audit is completed. The audit will be made available to the department upon request. Ongoing, the CEO will be responsible to ensure the annual audit is completed after the close of each fiscal year. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of the Physician ' s and Physician's assistant hours, conducted on September 25-26, 2019, the facility failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.A schedule was submitted that indicated the hours worked for the physician and the physician extender staff, as well as the patient census, for the period from June 2, 2019 through September 21, 2019. The facility was not in compliance for the following weeks:June 16-22, 2019: census 484, coverage 46 hrsJune 23-29, 2019: census 487, coverage 46 hrsJune 30-July 6, 2019: census 486, coverage 42.5 hrsJuly 7-13, 2019: census 479, coverage 42.5 hrsAugust 18-24, 2019: census 468, coverage 36 hrsSeptember 1-7, 2019: census 459, coverage 42.5 hrsSeptember 15-21, 2019: census 465, coverage 42.5 hrsThis information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Soar shall continue its effort to hire an additional full time Agency MD to have vacation coverage for the existing MD's and additional hours for patient services. In addition, as of 10/31/19, Soar Corp has hired an additional CRNP on a full time basis who will assist in patient care and coverage. The hiring of this additional CRNP staff brought the facility into compliance. The CEO of Soar will continue be responsible for the recruitment and hiring of an additional Agency MD. The regional project director shall monitor the MD's hours by completing time sheet reviews bi-weekly to ensure compliance. The regional project director shall make a request to add additional MD hours to the CEO. The recruitment and hiring of a MD shall be ongoing by the CEO.
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715.7(a)(1-2) LICENSURE Dispensing or administering staffing
(a) A narcotic treatment program shall be staffed as follows:
(1) If it operates an automated dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 200 patients.
(2) If it operates a manual or nonautomatic dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 150 patients.
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Observations
Based on a review of the dispensing staff hours, conducted on September 25-26, 2019, the facility failed to ensure that one full-time nurse was available for every two-hundred patients.A schedule was submitted that indicated the hours worked for the nursing staff, as well as the patient dosing census for each day, for the period from June 2 through September 21, 2019. The facility was not in compliance for the following days:Monday June 10, 2019: dosing census was 433 which required 18.4 coverage hours; however only 17 hours were documented. One nurse worked 9 hours, and one nurse worked 8 hours.Thursday July 4, 2019: dosing census was 440 which required 18.7 coverage hours; however only 12.5 hours were documented. One nurse worked 6.1 hours, and one nurse worked 6.4 hours.Friday August 9, 2019: dosing census was 404 which required 17.7 coverage hours; however only 14.6 hours were documented. One nurse worked 8.3 hours, and one nurse worked 6.3 hours.This information was reviewed with the facility staff during the licensing inspection.Gregg Hummel 10/1/19
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Plan of Correction
As of 11/21/19, a current LPN employed at Soar will transition to full time status from a part time status increasing the nursing hours by 20 per week and ensuring full compliance with the regulation. As of 11/1/19, a temporary LPN from a staffing agency was hired creating an additional 20 hours of nursing time. As of 11/1/19, the nurse manager is providing dosing coverage for call outs and shortages resulting in a additional 10 hours of coverage per week. As of 11/9/19, weekly time sheet reviews show Soar to be in compliance, having 3 nurses scheduled for each day of the week. Long Term, Soar shall continue its effort to hire a 2 additional full time Nurses to assist in providing coverage for vacations and for staff call outs. The Nurse Manager of Soar will be responsible for the recruitment and hiring of 2 additional nurses within the next 45 days (12/23/19). Weekly, the nurse manager shall monitor the nursing hours by completing time sheet reviews to ensure nursing hour compliance. The nurse manager shall make a request to add additional nursing staff to the CEO for approval. The recruitment and hiring of nurses shall be ongoing |
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 September 23-27, 2019, the facility failed to ensure a urinalysis is completed monthly in client records #9 and #11.Client #9 was admitted on 8/17/18. The urinalysis was missing for the month of August 2019.Client #11 was admitted on 8/9/17. The urinalysis was missing for the month of April 2019. This information was reviewed with facility staff during the inspection. Nate Myers 10/02/19
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Plan of Correction
Patient 9 and for patient 11 both had a UDS completed for the time frame indicated and the results were contained in the file of the time of inspection. Both UDS screens are part of the electronic medical records within Tower Systems to validate the collection and completion. Soar will continue to file material within 3 business days of the completion of a document and the clinical supervisor shall continue to complete chart audits on a quarterly basis on at least 10% of the charts to ensure compliance |
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
The facility failed to provide the required 2.5 hours of psychotherapy in the first two years in two client records.Eleven client records were reviewed on September 24-27, 2019. The facility failed to document that clients in the first two years of treatment received 2.5 hours of psychotherapy a month in two of these records. Client #1, an active MAT client, was admitted on 5/31/19 and was an active client at the time of the inspection. Client #1 received only 2 hours of psychotherapy in July, 2019 and 1 hour of psychotherapy in August, 2019.Client #2, an active MAT client, was admitted on 5/28/19 and was an active client at the time of the inspection. Client #2 received only 2 hours of psychotherapy in July, 2019.This information was reviewed with facility staff during the inspection. This is a repeat citation.Nate Myers 10/02/19
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Plan of Correction
Client one continued to miss over 50% of daily dosing during the month cited and patient 2 missed over 60% of doing during the month being cited and the rate of no shows resulted in the patient not meeting the minimum treatment standards. As of 11/12/19, the clinical supervisors shall run the "patients not counseled report" every two weeks to identify patients who are non-complaint with treatment standards and fail to meet minimum standards. The clinical Supervisor will establish an action plan with the primary counselor to address the identified patient and their patterns of non-compliance during the weekly supervision meetings. This discussion will be documented in the supervision notes of the counselor. Ongoing, Counselors will write a monthly non-billable note to reflect and document significant gaps of service, the dates of missed sessions, any issues of non- compliance with treatment and any interventions implemented. The program director shall be responsible for monitoring and compliance. The new system will be in effect by 11/24/19 to allow notification of staff |
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
The facility plan of correction states that intake staff will fax the notification to the receiving facility on the day of the transfer, however the following deficiencies were found.Based on a review of client records on September 23-27, 2019, the facility failed to notify the transferring facility of the client's initial dose in client records #2 and #7.Client # 2 was admitted on 05/28/19.Client #7 was admitted on 07/31/19. This information was reviewed with facility staff during the inspection. Nate Myers 10/02/19
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Plan of Correction
The program director shall offer refresher training to the intake and admission staff regarding the transfer procedures between narcotic treatment programs. Training shall include notifying an inpatient transferring narcotic treatment program of the admission of the patient at Soar and the date of the initial dose given to the patient by Soar Corp. The refresher training will be completed by 11/15/19. The Program Director shall audit any transfers in within 1 week of admission to ensure completion. The process will be ongoing |
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 September 23-27, 2019, the facility failed to ensure that the facility completes an annual evaluation of the client in client record #11. Client #11 was admitted on 8/09/17 and their annual evaluation was to be completed on 8/16/19. There was no record of this evaluation in the client file. This information was reviewed with facility staff during the inspection. Nate Myers 10/02/19
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Plan of Correction
The annual clinical review being referenced was completed on time and filed at the time of the onsite inspection. Soar shall follow the following plan to ensure filing is complete and accurate. Soar will continue to file material within 3 business days of the completion of a document. The clinical supervisor shall continue to complete chart audits on a quarterly basis on at least 10% of the charts to ensure compliance. Any misfiled or missing documents found shall be corrected within 1 week of the finding |
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 September 23-27, 2019, the facility failed to complete a psychosocial evaluation for clients #5, #6 and #7.The facility's policy states that the clinical summary is to be completed no later than 30 days after the psychosocial assessment tool. Client #5's psychosocial evaluation was completed 3/20/19 however, the clinical summary was not completed until 5/3/19.Client #6's psychosocial evaluation was completed 8/15/19 however, the clinical summary was not documented in the client record at the time of the inspection.Client #7's psychosocial evaluation was completed 7/31/19 however, the clinical summary was not completed until 9/1/19.This information was reviewed with facility staff during the inspection. Nate Myers 10/02/19
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Plan of Correction
As of 10/24/19, the Regional Project Director has modified the current excel chart grid to track due dates for the 30 day psychosocial clinical summery. Within one week of being due, the chart grid will now highlight a treatment plan, case conference, clinical annual and the 30 day psychosocial clinical summery that needs to be completed. The grid is viewable to all counseling staff and supervisors. During the supervision sessions, the chart grid shall be reviewed by the supervisor. The clinical supervisors shall monitor documentation completion and establish a POC with counselor for any incomplete documents. The discussion and plan to address the issue will be reflected in the supervision notes |
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
The facility plan of correction states that they will use secondary documentation, in the form of a non-billable note, to indicate scheduled sessions not attended by clients, however this was not implemented at the time of the inspectionBased on a review of client records on September 23-27, 2019, the facility failed to provide counseling per the client's treatment plan in three client records.Client #1'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 and July 2019 there were no group sessions documented. In addition, there was no documentation of an individual session during the week of 6/24/19. Client #2 ' 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). No individual sessions were documented during the weeks of 6/2/19, 6/9/19,7/7/19,7/14/19,7/21/19, 8/11/19, 9/1/19 and 9/8/19. In addition, there was no documentation of a group session during the week of 6/16/19, 6/23/19, 6/30/19, the month of July and August. Client #3'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). No individual sessions were documented during the weeks of 6/30/19, 7/7/19, 8/4/19, 8/18/19, 8/25/19 and 9/8/19. In addition, there was less than three group sessions documented during the weeks of 7/28/19, 8/4/19, 8/18/19, 8/25/19, 9/1/19 and 9/8/19. 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). No individual sessions were documented during the weeks of 3/24/19, 4/14/19, 4/28/19, 5/19/19, 5/26/19, 6/2/19, 6/30/19,7/7/19, 7/14/19, and 7/21/19. In addition, there was no documentation of a group session during the week of 4/7/19, 4/19/19, 4/28/19, 5/5/19, 5/19/19, 5/26/19, the month of July 2019 and August 2019. Client #10 ' 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). No individual sessions were documented between 4/28/19 and 6/23/19. Client #11 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). No individual sessions were documented during the weeks of 5/05/19 and 5/12/19. This information was reviewed with facility staff during the inspection. Nate Myers 10/02/19
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Plan of Correction
Soar has determined the prior plan of correction is impractical. Instead, counselors will write a monthly non-billable note to reflect significant gaps of service, non- compliance with treatment and any interventions implemented. The program director shall be responsible for monitoring and compliance. The new system will be in effect within 30 days 11/24/19 to allow notification of staff |
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 September 23-27, 2019, the facility failed to ensure that the client file contained a complete case consultation for client #11. Client #11 ' s case consultation dated 8/25/19 was signed by his counselor. There were no other facility staff that participated in the consultation. This information was reviewed with facility staff during the inspection. Nate Myers 10/02/19
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Plan of Correction
Effective of as 10/24/19, clinical supervisors shall review and sign all clinical case conference notes prior to filing. The program direction will be responsible for ongoing compliance. |