INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 26, 2023 through September 27, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SOAR Corp was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2022 through December 31, 2022 training year in two of three applicable personnel records reviewed.
Employee # 10 was hired as a counselor on November 28, 2018. The personnel record documented 0 hours of training received during the training year reviewed.
Employee # 11 was hired as a counselor on December 14, 2015. The personnel record documented 0 hours of training received during the training year reviewed.
This is a repeat citation from the November 8, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 10/15/2023 a google share drive document has been established to track the training requirements for staff. The regional director has shared the document with the program directors and clinical supervisors of the agency. Monthly during a supervision session, the supervisor shall review the required trainings with the staff member and assist with locating trainings as needed. Quarterly, the HR assistant will review the training grid and email each staff member to review their current training hours and outline required trainings to complete. The first email notification shall be sent within 30 days (11/15/23) and the program director shall monitor for completion. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the facility's November 2022 through August 2023 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The fire drill logs, for every monthly drill conducted during the reviewed period, documented that the front exit was utilized as the exit route and no other alternative exit routes were used.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
11/27/23, the regional project director will send an instructional memo to the staff of the facility by e-mail regarding the fire drill procedure. The memo will instruct that the staff must use alternative exits to leave the facility during the monthly drills. Alternative exist shall include the emergency hallways from the second floor, the 3 exits in the atrium and the back exit from the medical hallway. The memo states that the use of the specific alternative exit shall be noted and indicated on the fire drill form. At the close of each month, the program director will be responsible to review the completed fire drill form to ensure it is complete and accurate. This process will start as 11/27/23 and shall be ongoing. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of seven client records reviewed.
Client # 4 was admitted on February 10, 2020 and was discharged on September 5, 2023. The release of information form to the funding source was completed on August 29, 2023, but the form did not document the dated signature of the client.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The program director shall offer an internal training on the topic of releases and confidentiality by 11/27/2023. Proof of the training shall be placed in the employees HR file in the form of a certificate. The training will cover proper release formulation, dating and signing the roi, the need to complete an informed and voluntary consent prior to the disclosure of information and the review of the 42CFR regulations. To ensure compliance the program director and qi staff shall audit a sample of charts monthly to ensure the procedure above is followed. The program director shall address ongoing issues in this area during the supervision process. This process will start as of 11/27/23 and shall be ongoing. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on a review of patient records, the facility failed to verify the individual's identity including the name, address and date of birth prior to the administration of an agent in two of three applicable patient records reviewed.
Client # 1 was admitted on January 5, 2023 and was still active at the time of the inspection. There was no documentation in the patient record that the patient's identity was verified prior to the administration of an agent.
Client # 5 was admitted on January 18, 2023 and was discharged on June 29, 2023. There was no documentation in the patient record that the patient's identity was verified prior to the administration of an agent.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An instructional memo will be sent out by the regional project director by email regarding Patient identification at the time of admission. The memo will state that staff must verify the individual's identity including the name, address and date of birth prior to the administration of an agent. The memo will state that the staff must receive a form of a picture that includes the identifiers listed above. If a patient does not have a picture identification, the staff will be instructed to help the patient obtain this item prior to the administration of an agent. Monthly, the QI department will audit all new intakes to ensure the plan is followed and documentation is noted in the chart. Occurrence of missing documents shall be sent to the program director for correction. Process will be start as of 11/27/23 and 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.
|
Observations
Based on a review of patient records, the facility failed to complete and document a random urinalysis, for each patient, at least monthly in three of seven applicable patient records reviewed.
Patient # 2 was admitted on February 23, 2023 and was still active at the time of the inspection. There was no documentation that a random urinalysis was conducted during the month of April 2023.
Patient # 3 was admitted on March 31, 2017 and was still active at the time of the inspection. There was no documentation that a random urinalysis was conducted during the month of July 2023.
Patient # 4 was admitted on February 10, 2020 and was discharged on September 5, 2023. There was no documentation that a random urinalysis was conducted during the months of July 2023 and August 2023.
This is a repeat citation from the November 8, 2022 annual licensing inspection.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
As of 11/27/23, the nursing manager will run a "patient without a uds report" from the EMR system twice a month to identify the patients who have not completed the minimum UDS screening requirements. Patient identified by this method shall be placed on hold to complete a sample. Patients who refuse to complete the screenings shall have a Non-billable medical note placed in their emr record to indicate the attempt and refusal to complete. To ensure compliance at the end of each month, the qi staff shall run "patient without a uds report" and audit the patient's chart for a nonbillable note. A chart lacking a nonbillable note shall be sent to the nursing manager for correction. The process will be ongoing as of 11/27/23 |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to document that it transferred patient files, including medical and psychosocial summaries and urinalysis reports or summary, in one of one applicable patient records reviewed.
Patient # 6 was admitted on November 10, 2014 and was transferred to another narcotic treatment program on February 10, 2023. The record did not include documentation that the transferring narcotic treatment program transferred the medical and psychosocial summaries and urinalysis reports or summary of the patient to the new narcotic treatment program.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
An instructional memo will be sent out by the regional project director by email regarding patient transfer out. The memo will state that the primary counselor will be responsible to include the medical summaries (physical, dosing hx, blood work, tb results), psychosocial summaries and urinalysis reports as part of as part of a transfer out packet. The memo will also state that the transfer out packet must be sent within 7 days of a patient requesting a transfer. The transfer out packet form will be emailed to the contact person of the transferring narcotic treatment program. The email sent shall serve as documentation that transfer request was completed and will document the information sent within the transfer packet. A copy of the email will be scanned into the patients' emr to serve as proof. A copy of the transfer out packet will be scanned into the patients' emr to serve as proof. Monthly, the QI department will audit all transfer out monthly to ensure the plan is followed and documentation is noted in the chart. Occurrence of missing documents shall be sent to the program director for correction. Process will be start as of 11/27/23 and shall be ongoing |
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient records reviewed.
Patient # 2 was admitted on February 23, 2023 and was still active at the time of the inspection. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date the initial dose was given.
This is a repeat citation from the November 8, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An instructional memo will be sent out by the regional project director regarding patient transfers. The memo will state that the intake counselor will be responsible to fill out Soar's dose verification form and document the date of the admission of the patient and the date of the initial dose given on the form. The Dose verification form will be emailed to the contact person of the transferring narcotic treatment program at the time of admission. The email sent shall serve as the document in writing that the transferring program has been notified of the admission. A copy of the email will be scanned into the patients' emr to serve as proof. Monthly, the QI department will audit all new intakes to ensure the plan is followed and documentation is noted in the chart. Occurrence of missing documents shall be sent to the program director for correction. Process will be start as of 11/27/23 and shall be ongoing |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in four of seven applicable client records reviewed.
Client # 1 was admitted on January 5, 2023 and was still active at the time of the inspection. A treatment plan update was completed on April 7, 2023 and another update was due no later than June 7, 2023; however, the update was not completed until June 22, 2023. Additionally, a treatment plan update was completed on June 22, 2023 and another update was due no later than August 22, 2023; however, the update was not completed at the time of the inspection.
Client # 2 was admitted on February 23, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 17, 2023 and another update was due no later than July 17, 2023; however, the update was not completed at the time of the inspection.
Client # 3 was admitted on March 31, 2017 and was still active at the time of the inspection. A treatment plan update was completed on December 16, 2022 and another update was due no later than February 16, 2023; however, the update was not completed until March 3, 2023. Additionally, a treatment plan update was completed on June 23, 2023 and another update was due no later than August 23, 2023; however, the update was not completed until September 19, 2023.
Client # 7 was admitted on April 14, 2014 and was discharged on August 20, 2023. A treatment plan update was completed on May 8, 2023 and another update was due no later than July 8, 2023; however, the update was not completed until July 31, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 10/16/23 the regional project director and the EMR vendor have updated the audit reports within the EMR system for treatment planning. The audit report number 147d and 147e entitled Treatment plans due within a date range and overdue treatment plans will be used to identify upcoming and late treatment plans. As of 11/2/23, a directive will be sent by email to the clinical supervisors and program directors stating that these reports must be completed on a weekly basis to identify areas of correction. Incomplete, late, or upcoming treatment plans on the report shall be corrected by counselor within 1 week, and the clinical super shall follow up to ensure completion. At the end of each month, The QI department will review the audit reports to ensure completion. The process will start as of 11/16/2023 and will be ongoing |