INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 27 through 28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corp. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on January 29, 2011.
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Plan of Correction
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2009 annual report and an interview with the project director, the governing body failed to make available to the public an annual report which included a financial statement of income and expenses, as required by regulation.
The findings include:
The 2009 annual report was reviewed on December 27, 2010. The facility is publicly funded and required by regulation to make available to the public an annual report which includes a financial statement of income and expenses. On December 16, 2010, the facility made available to the public the 2009 annual report. The 2009 annual report did not include a financial statement of income and expenses.
On December 29, 2010 at approximately 10:15 PM the project director was interviewed. The project/facility director confirmed that a financial statement of income and expenses had not been included in the annual report.
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Plan of Correction
The Project Director will include a financial statement of income and expenses, as required by regulation for the 2009 annual report and each year thereafter. The Project Director will review and monitor the report prior to the release to ensure this defiency does not recur. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in three of sixteen client records.
The findings include:
Sixteen client records were reviewed on December 27, 2010 for consent to release information forms from the client prior to the disclosure of information. Three of the sixteen records, #'s 2, 3, and 14, documented that urine drug screens had been sent out to a lab, but there was not documentation of a consent form signed by the clients.
Client record #2 was admitted on 10-1-10. Urine drug screen reports had been completed by the lab on 10-11-10; 10-25-10; 11-3-10; 11-9-10; and 11-17-10. There was not a consent form allowing for the disclosure of information to the laboratory who conducted the analysis.
Client record #3 was admitted on 10-18-10. Urine drug screen reports had been completed by the lab on 10-11-10; 10-25-10; 11-3-10; 11-9-10; 11-11-10; 11-17-10; and 12-2-10. There was not a consent form allowing for the disclosure of information to the laboratory who conducted the analysis.
Client record #14 was admitted on 10-4-10. Urine drug screen reports had been completed by the lab on 10-13-10; 10-19-10; 10-28-10; 11-9-10; 11-16-10; and 11-23-10. There was not a consent form allowing for the disclosure of information to the laboratory who conducted the analysis.
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Plan of Correction
The Clinical Supervisor will meet and train the intake worker and clinical staff to ensure all informed and voluntary consents from the patients are completed properly for the labs and any other disclosure of information contained in the patient record. The
Clinical Supervisor will also perform weekly inspections of charts to ensure this deficency does not recur. |
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 and the administrative policy and procedures manual, the facility failed to document a psychosocial evaluation within ten days as per facility policies and procedures in six of of fourteen outpatient client records reviewed.
The findings include:
Fourteen client records were reviewed on December 27-28, 2010. The facility's policy states that biopsychosocial evaluations are to be completed within ten days of admission. Fourteen client records required the completion of psychosocial evaluations. Six client records did not include a biopsychosocial evaluation that had been completed within ten days of admission, specifically records # 1, 2, 3, 7, 13, and 15.
Client # 1 was admitted on 11-18-2010. The psychosocial evaluation was due on 11-28-10, and had not been completed until 12-3-2010.
Client # 2 was admitted on 10-1-2010. The psychosocial evaluation was due on 10-11-10, and had not been completed until 10-15-2010.
Client # 3 was admitted on 10-18-2010. The psychosocial evaluation was due on 10-28-10, and had not been completed until 11-2-2010.
Client # 7 was admitted on 10-28-2010. The psychosocial evaluation was due on 11-07-10, and had not been completed until 11-13-2010.
Client # 10 was admitted on 9-13-2010. The psychosocial evaluation was due on 9-23-10, and had not been completed as of the date of inspection.
Client # 13 was admitted on 9-30-2010. The psychosocial evaluation was due on 10-10-10, and had not been completed until 10-15-2010.
Client # 15 was admitted on 7-9-2010. The psychosocial evaluation was due on 7-19-10, and had not been completed until 7-21-2010.
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Plan of Correction
The Clinical Supervisor will meet and train the intake worker and clinical staff to ensure psychosocial evaluations are completed within ten days of admission. The Clinical Supervisor will monitor weekly to ensure this deficency does not recur. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to document treatment plans to include proposed types of supportive services in ten of sixteen client records.
Findings:
Sixteen client records were reviewed on December 27-28, 2010. The facility's policy states that each individual treatment plan will include proposed type of support services. Treatment plans with proposed types of supportive services were required in fifteen client records. The facility did not document treatment plans to include proposed types of supportive services in client records # 2, 4, 5, 6, 8, 11, 13, 14, 15, and 16.
Client # 2 was admitted on 10-1-10, the treatment plan was completed on 10-29-10 and did not include proposed support services.
Client # 4 was admitted on 7-22-10, the treatment plan was completed on 8-22-10 and did not include proposed support services.
Client # 5 was admitted on 7-6-10, the treatment plan was completed on 8-6-10 and did not include proposed support services.
Client # 6 was admitted on 7-16-10, the treatment plan was completed on 8-14-10 and did not include proposed support services.
Client # 8 was admitted on 7-30-10, the treatment plan was completed on 7-30-10 and did not include proposed support services.
Client # 11 was admitted on 9-9-10, the treatment plan was completed on 10-8-10 and did not include proposed support services.
Client # 13 was admitted on 9-30-10, the treatment plan was completed on 11-1-10 and did not include proposed support services.
Client # 14 was admitted on 10-4-10, the treatment plan was completed on 11-1-10 and did not include proposed support services.
Client # 15 was admitted on 7-9-10, the treatment plan was completed on 8-9-10 and did not include proposed support services.
Client # 16 was admitted on 9-27-10, the treatment plan was completed on 9-27-10 and did not include proposed support services.
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Plan of Correction
On December 29, 2010 treatment plans forms have been change to include proposed support services. Clinical Supervisor met and trained staff to document support services on treatment plans. The Clinical Supervisor will monitor and sign off on all treatment plans to ensure this deficency does not recur. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to document discharge summaries to include services offered and and the patient's status/prognosis in six of six client records.
Findings:
Six records of discharged clients were reviewed on December 27-28, 2010 for documentation of a discharge summary. The facility's policy states within one week of discharge, a discharge summary will be completed by a counselor describing reason for treatment services offered, response to treatment, and patient's status/prognosis.
The facility did not document discharge summaries to include services offered and and the patient's status/prognosis in patient records # 11, 12, 13, 14, 15, and 16.
Client # 11 was discharged on 10-22-10, the discharge summary was completed on 10-27-10 and did not include services offered and and the patient's status/prognosis.
Client # 12 was discharged on 10-14-10, the discharge summary was completed on 10-14-10 and did not include services offered and and the patient's status/prognosis.
Client # 13 was discharged on 12-17-10, the discharge summary was completed on 12-17-10 and did not include services offered and and the patient's status/prognosis.
Client # 14 was discharged on 12-9-10, the discharge summary was completed on 12-9-10 and did not include services offered and and the patient's status/prognosis.
Client # 15 was discharged on 12-13-10, the discharge summary was completed on 12-13-10 and did not include services offered and and the patient's status/prognosis.
Client # 16 was discharged on 12-22-10, the discharge summary was completed on 12-23-10 and did not include services offered and and the patient's status/prognosis.
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Plan of Correction
The Clinical Supervisor will change the discharge summary form to include; services offered, patient's status/prognosis, and response to treatment. Clinical Supervisor then will meet and train all clinical staff on documentation of discharge summary and will monitor and sign off on each discharge summary to ensure this deficency does not recur. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of patient records and the facility's policies and procedures, the facility failed to document a follow-up attempt in one of the two records reviewed.
The findings include:
On December 27-28, 2010, two client records requiring documentation of follow-us were reviewed.
The facility's policy states:
When a patient is is referred to an outside agency, contact is to be made to the referred agency within one week of the referral to. If no referral is made, contact is to be attempted within 30 days of discharge. The follow up attempts are to be documented in the patient's record.
Client # 11 was discharged on 10-22-10, a referral had been made to another agency and a follow-up attempt was required to be documented by 10-29-10. As of the date of inspection, no follow-up attempt had been documented in patient record #11.
The project director confirmed that the follow up attempts in these client records were not documented at the time of the licensing inspection.
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Plan of Correction
The Clinical Supervisor will meet and train all clinical staff on; contact and documentation of follow-up within one week after a patient is referred, and within 30 days after a patient is discharged. The clinical Supervisor will monitor and sign off on all discharges to ensure this deficency does not recur. |