INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 20, 2024 through August 21, 2024 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 - Warminster was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of nine client records reviewed.
Client #5 was admitted on December 28, 2023 and was active at the time of inspection. A release of information form to the emergency contact was signed and dated by the client on December 28, 2023; however, the name of the person, agency or organization was not documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director shall offer an internal training on the topic of releases and confidentiality by 11/1/2024. 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, the need to complete an informed and voluntary consent prior to the disclosure of information and the review of the 42CFR regulations. Training will cover the need to ensure the specific names of emergency contacts, and others must be listed within the ROI being signed. 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. Patient 5 will be asked to sign a release for the treatment provider noted by 11/1/2024. This process will start as of 11/1/2024 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.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in the record, the emergency contact as part of the verification of the individual in one of five applicable patient records reviewed.
Patient #5 was admitted on December 28, 2023 and was active at the time of the inspection. There was no documentation of the patient's emergency contact in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Once a week, the program director and the quality assurance assistant will run the patient's admission report from the emr to identify new admissions. Full chart audits will be completed by the quality assurance assistant on the new admissions to ensure the initial documentation is compete , accurate and includes a emergency contact along with a ROI for a emergency contact. Occurrences of missing or incomplete documents will be addressed by the program director. Corrections to the documents will be completed and given to the program director within 1 week. This process will start as of 10/1/24 and shall be ongoing. |
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 patient records, the narcotic treatment program failed to ensure each patient received an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in four of five applicable patient records reviewed.
Patient #2 was admitted on May 14, 2023 and was discharged on May 30, 2024. The record of service and progress notes indicated 2 hours of psychotherapy were provided during the month of January 2024, 0 hours of psychotherapy during the month February of 2024, and 5 minutes of psychotherapy during the month of March 2024.
Patient #3 was admitted on January 8, 2024 and was discharged on May 24, 2024. The record of service and progress notes indicated 0 hours psychotherapy were provided during the month of February 2024 and 30 minutes of psychotherapy during the month of March 2024.
Patient #5 was admitted on December 28, 2023 and was active at the time of the inspection. The record of service and progress notes indicated 0 hours of psychotherapy were provided during the month of February 2024.
Patient #6 was admitted on December 26, 2023 and was active at the time of the inspection. The record of service and progress notes indicated 0 hours of psychotherapy were provided during the month of January 2024.
This is a repeat citation from the September 22, 2023 and November 7, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 11/1/2024, the location moves from the voluntary attendance of therapy sessions that include group and individual sessions and shall return to enforcing mandatory attendance of group and individual therapy sessions. Weekly the program director will run the patients not counseled report to identify patient who have not attended their sessions as required and they will be placed on "hold" to complete. Patients who refuse to attend the 2.5 hours of treatment will have this documented in their chart. The process of completing a weekly review and holding patients will be ongoing by the program director to ensure treatment sessions are completed and adherence to the regulation is met
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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 patient records, the narcotic treatment program failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and was also reviewed, dated, and signed by the medical director in four of four applicable patient records reviewed.
Patient #1 was admitted on December 8, 2021 and was discharged on January 11, 2024. The annual evaluation of the patient's status was completed by the counselor on December 28, 2023 and signed by a narcotic treatment physician on January 2, 2024; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient #2 was admitted on May 14, 2023 and was discharged on May 30, 2024. The annual evaluation of the patient's status was completed by the counselor on April 29, 2024 and signed by a narcotic treatment physician on April 30, 2024; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient #4 was admitted on December 3, 2019 and was discharged on February 23, 2024. The annual evaluation of the patient's status was completed by the counselor on December 8, 2023 and signed by a narcotic treatment physician on December 12, 2023; however, the evaluation was not reviewed, dated, and signed by the medical director.
Patient #7 was admitted on October 23, 2020 and was active at the time of the inspection. The annual evaluation of the patient's status was completed by the counselor on October 23, 2023 and signed by a narcotic treatment physician on October 24, 2023; however, the evaluation was not reviewed, dated, and signed by the medical director.
This is a repeat citation from the September 22, 2023 and November 7, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The regional project director will send a instructional memo by 10/1/24 to the medical staff regarding the clinical annual document. The memo will state by regulation, the clinical annual review document cannot be signed by a medical doctor of the facility and can only be signed by the Medical Director of the corporation. The memo will state that if the Medical director is on vacation and another narcotic Physician is covering, the covering MD does not have the authority to sign the clinical annual document, even if it will be out of compliance for a late signature. To ensure compliance with the plan a qi member will audit the document for appropriate signatures. The audit process will begin as of 10/1/24 |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for documenting an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was submitted and approved by the Department for the November 7, 2022 and September 22, 2023 annual licensing inspections. Not documenting an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was again found to be a deficiency in the August 20, 2024 through August 21, 2024, annual licensing inspection.
A plan of correction for not having the medical director review, date, and sign the annual, clinical evaluation of the patient's status was submitted and approved by the Department for the November 7, 2022 and September 22, 2023 annual licensing inspections. Not having the medical director review, date, and sign the annual, clinical evaluation of the patient's status was again found to be a deficiency in the August 20, 2024 through August 21, 2024, annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The regional project director has recommended seeking out and hiring a QI Manager for the agency to the board of directors and CEO of the corporation. The QI Manager will be responsible to for auditing and following up on the plans of correction issued in order to ensure compliance is met. The approval and hiring process for the position should be completed by 12/1/2024
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