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 7, 2025 through August 8, 2025 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:
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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, the facility failed to ensure that each counselor employed met the regulatory qualifications of the position in one of six applicable personnel records reviewed.
Employee # 6 was hired as a counselor on May 20, 2025 and was still in the position at the time of the inspection. The employee had a bachelor's degree in economics; however, the major is not in the field of chemical dependency, psychology, social work, counseling, or nursing and the major is not identified as a related field, per Licensing Alert 03-2021. There was no other documentation, in the personnel record, indicating the employee met the educational requirements of the position at the time of hire.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By September 19, 2025, the employee will transition from a Full Counselor to an Assistant Counselor. This requires them to sign a new job description, complete a new training plan, and begin weekly supervision to ensure regulatory compliance. The employee must also pursue a CADC certification to meet professional standards, and the Program Director will monitor the completion of these steps. Additionally, effective September 19, 2025, the Human Resources department will implement a new, ongoing process. Before an offer letter is extended to any potential counselor candidate, both the human resource department and the Regional Director will verify that the candidate's degree and major align with the official DDAP list to ensure full compliance. This process will 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
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of seven applicable personnel records reviewed.
Employee # 5 was hired as a counselor assistant on July 22, 2024 and promoted to a counselor on July 22, 2025. The employee was due to have the HIV/AIDs and TB/STD trainings no later than July 22, 2025 however; both trainings were not completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective August 15, 2025, a new shared electronic network document has been created to track staff training requirements. The Regional Director has shared this document with all Program Directors and Clinical Supervisors. During scheduled supervision sessions, supervisors will now review required training with their staff, offering assistance in locating necessary courses as needed. Supervisors will document the outcomes of these discussions in the supervision notes. Additionally, the HR Assistant will conduct a monthly review of the training grid. Within 30 days of this notice (September 15, 2025), the HR Assistant will send the first email to all staff, outlining their current training hours and required courses. The employee mentioned in the report is expected to schedule the specified training within 60 days of receiving this email. The Program Director will monitor the employee's progress to ensure completion. |
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 an administrative review, the facility failed to 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.
At the time of the inspection, there was no financial audit completed for the project ' s fiscal year ending June 30, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within the next 90 days, Soar Corp will contract with an independent certified public accountant to perform an annual financial audit for the project's fiscal year ending June 30, 2024. The CEO of Soar is responsible for this process, with the immediate goal of securing a completed audit within the 90-day time frame. The CEO will also ensure all future audits are completed within 90 days of their respective fiscal year-ends to maintain compliance with all relevant standards. |
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, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of eight client records reviewed.
Client # 1 was admitted on January 28, 2025 and was still active at the time of the inspection. There was evidence of a disclosure to another treatment provider on January 28, 2025; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 2 was admitted on November 20, 2019 and was discharged on June 9, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By October 1, 2025, the Program Director will provide an internal training on releases and confidentiality. The training will cover proper release formulation, the need for informed and voluntary consent before disclosing information, and a review of 42 CFR regulations. It will also emphasize that specific names of emergency contacts and other individuals must be listed on a signed release of information (ROI). Additionally, the training will address the importance of obtaining consent before sharing transfer-in, transfer-out, and dosing information. Finally, the Program Director and the administrative assistant will conduct a monthly audit of a sample of charts to ensure this procedure is followed. The Program Director will address any ongoing issues during supervision sessions, and proof of the training will be placed in each employee's HR file in the form of a certificate. |
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 an administrative review, the narcotic treatment program failed to ensure narcotic treatment physician services were provided at least 1 hour per week onsite for every ten patients.
During the week of March 18, 2025 through March 24, 2025, the patient census was 421. This required 42.1 onsite physician hours; however, there were only 34 physician hours documented for the week.
During the week of July 1, 2025 through July 7, 2025, the patient census was 467. This required 46.7 onsite physician hours; however, there were only 40 physician hours documented for the week.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Soar is making a concerted effort to expand its medical staff by hiring an additional Medical Doctor (MD). This will allow the organization to extend patient service hours and ensure continuous coverage during existing MDs' vacations. The CEO of Soar will lead the recruitment and hiring efforts, with the immediate goal of securing a candidate within 90 days. This process will be ongoing to meet future needs. The CEO will also be responsible for monitoring the MD-to-patient census ratio to ensure it remains in compliance with all relevant standards |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on an administrative review, the narcotic treatment program failed to ensure one-third of all required narcotic treatment physician time was provided by a narcotic treatment physician and no more than two-thirds of the required time was provided by a physician assistant or certified registered nurse practitioner.
During the week of April 8, 2025 through April 14, 2025, the patient census was 424. This required 42.4 total narcotic treatment physician hours, with at least 14.133 of those hours to be provided by a narcotic treatment physician. The narcotic treatment physicians provided only 10 hours of the required time, while the physician assistant and certified registered nurse practitioner provided a total of 40 hours of required time for the week.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Soar is making a concerted effort to expand its medical staff by hiring an additional Medical Doctor (MD). This will allow the organization to extend patient service hours and ensure continuous coverage during existing MDs' vacations. The CEO of Soar will lead the recruitment and hiring efforts, with the immediate goal of securing a candidate within 90 days. This process will be ongoing to meet future needs. The CEO will also be responsible for monitoring the MD-to-patient census ratio to ensure it remains in compliance with all relevant standards |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure the narcotic treatment physicians determined and ordered the initial dosage level for a patient in three of three applicable patient records reviewed.
Client # 1 was admitted on January 28, 2025 and was still active at the time of the inspection. The initial methadone dose, dated January 28, 2025, was determined and ordered by a certified registered nurse practitioner, not a narcotic treatment physician.
Client # 3 was admitted on January 8, 2025 and was still active at the time of the inspection. The initial methadone dose, dated January 8, 2025, was determined and ordered by a certified registered nurse practitioner, not a narcotic treatment physician.
Client # 7 was admitted on January 16, 2025 and was discharged on May 25, 2025. The initial methadone dose, dated January 16, 2025, was determined and ordered by a certified registered nurse practitioner, not a narcotic treatment physician.
This is a repeat citation from the August 14, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Project Director will email a memo by October 1, 2025, to the corporate medical team regarding Regulation 715.15b. This memo will clarify that only a narcotic treatment physician can determine and order a patient's initial narcotic dosage at admission. CRNPs and PAs are not permitted by Regulation 715.15b to set initial doses, but they are authorized to adjust subsequent doses and issue take-home doses. Beginning October 1, 2025, the QI department will conduct ongoing audits of all new admissions within 30 days to ensure compliance. Any instances of non-compliance will be reported to the Medical Director for corrective action |
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 patient records, the narcotic treatment program failed to document the results of all annual physical examinations given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician, in two of four applicable patient records reviewed.
Patient # 2 was admitted on February 27, 2023 and was still active at the time of the inspection. The most recent annual physical examination was completed on February 22, 2024 and the next annual physical was due to be completed by February 22, 2025; however, there was no updated physical exam documented in the record at the time of the inspection.
Patient # 8 was admitted on January 2, 2024 and was discharged on April 24, 2025. The most recent annual physical examination was completed on January 5, 2024 and the next annual physical was due to be completed by January 5, 2025; however, there was no updated physical exam documented 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
As of August 19, 2025, a new, ongoing procedure is in place to manage annual physical reviews. The Nursing Manager will use the EMR system's self-audit tools, specifically Report #150d (Annual Physical Dues in a Date Range), to identify any overdue or upcoming physical exams. The Nursing Manager will run this report every two weeks and share the results with the Program Director and the administrative assistant, who will then schedule the patient appointments. At the end of each month, the Nursing Manager or a designee will audit the results to confirm completion. Any missing or incomplete documents identified will be addressed by the Program Director. Staff members will have one week to complete all necessary corrections. The process will be ongoing, starting 9/1/2025 and monitored for compliance by the program director |
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 reviewed, dated and signed by the medical director in one of two applicable patient records reviewed.
Patient # 8 was admitted on January 2, 2024 and was discharged on April 24, 2025. There was no annual evaluation of the patient's status completed by the counselor documented in the record at the time of the inspection.
This is a repeat citation from the August 14, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of August 19, 2025, a new procedure is in place to track and manage clinical annual reviews. Program Directors will use the self-audit tools within the EMR system, specifically Report #151e (Annual Review/Assessments by Caseload), to identify any overdue or upcoming annual reviews. A directive has been sent via email to all clinical supervisors and program directors, requiring them to run this report every two weeks. Any missing or incomplete documents identified will be addressed by the program director, and staff will have one week to complete all necessary corrections. The process will be ongoing, starting 9/1/2025 and monitored for compliance by the program director |
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, the facility failed to maintain a complete client record, which is to include the documentation of a discharge summary, in two of four applicable client records reviewed.
Client # 7 was admitted on January 16, 2025 and was discharged on May 25, 2025. There was no discharge summary documented in the record at the time of the inspection.
Client # 8 was admitted on January 2, 2024 and was discharged on April 24, 2025. There was no discharge summary documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of September 1, 2025, a new, ongoing procedure is in place to manage discharge summaries. The administrative assistant will use the EMR system's self-audit tools, specifically Report #120 (Discharges by Reason in a Range), to identify patients who require a completed discharge summary within a specific timeframe. The administrative assistant will run this report every two weeks and audit each patient's record to verify if a discharge summary has been completed. A list of incomplete summaries will be shared with the Program Director, who will then address any missing or incomplete documents. Staff members will have one week to complete all necessary corrections. The process will be ongoing, starting 9/1/2025 and monitored for compliance by the program director |