INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12-13, 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 May 10, 2010.
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Plan of Correction
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709.22(e) 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:
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Observations
Based on a review of administrative documentation and an interview with the Project Director, the project failed to make an annual report available to the public.
The findings were:
Administrative documentation was reviewed on April 12, 2010. The failed to submit, upon request, an annual report for the 2008-2009 fiscal year. An interview with the Project Director on April 13, 2010 at approximately 9:15 am confirmed that the annual report for the 2008-2009 fiscal year had not been completed.
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Plan of Correction
Director will inform SOAR Board at special meeting called for 5/11/2010 that audit needs to be done for fiscal year in question. Report will be requested to be done by 6/30/10 so that it will be on file. This report will be done annually from this point on and will be built into 2nd Board meeting of each year so that it can be approved and request sent to SOAR accountant firm. Director will monitor for compliance. |
709.23(b)(2) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(2) Written reports of project operations.
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Observations
Based on a review of administrative documentation and the project's policies and procedures, the project failed to document written reports of project operations.
The findings were:
Administrative documentation was reviewed on April 12, 2010. The project's bylaw's stated that the Board of Directors will hold four quarterly meetings a year. The facility failed to provide documentation of board meeting minutes to verify the Board had been meeting on a quarterly basis.
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Plan of Correction
The documents in question were located in the front of the appendices book. There are 4 meetings with minutes for all 4 quarters of 2009 filed accordingly and will be sent to your office upon request. These minutes have been filed each year in the appendices with-in 30 days of the Board meeting by the Board Secretary. The Director will make sure that DAPL auditors will be shown where minutes are filed so that this will not happen again in the future. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of administrative documentation, the project failed to document written reports summarizing the progress towards meeting goals and objectives.
The findings were:
Administrative documentation was reviewed on April 12, 2010. A performance report on the project goals and objectives was recommended quarterly but required on at least an annual basis. The facility failed to document a written report on the progress of the goals and objectives for the 08-09 fiscal year as requested at the time of the inspection.
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Plan of Correction
Director will immediately write a progress / performance report on the SOAR goals for 2009 including what was completed, by who and what needs to be carried over or removed as a goal. this report will be done and prepared for the 1st Board meeting of each year for their acceptance and approval. Director will be responsible for this report each year. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative policies and procedures and an interview with the Project Director, the project failed to complete the annual audit of financial activities for the 2008-2009 fiscal year.
The findings include:
Administrative documentation was reviewed on April 12, 2010. The inspector could not locate an annual audit of financial activities for the 2008-2009 fiscal year. An interview with the Project Director on April 13, 2010 at approximately 9:20 am confirmed that an audit had not been completed for the previous fiscal year.
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Plan of Correction
Director will prepare special memo for SOAR Board that will include the regulation regarding an annual audit. Director will request Board to have audit done immediately for 2009 for it to be on file and Director will ensure that the Board approves one being done for each year that it is in operation. Director will monitor for compliance. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on a tour of the physical plant and an interview with the Administrative Assistant, the facility failed to post the service fee schedule in a a prominent place.
The findings include:
A tour of the plant was conducted on April 13, 2010. The facility failed to provide a fee schedule that was posted in a prominent location. An interview with staff verified that the fee schedule was not posted in a prominent location.
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Plan of Correction
Fee schedule was rehung while DAPL auditors still on site. Director will monitor and ensure that the fee schedule is always posted in a place in a common area for anyone who comes in to SOAR to be able to see the fees. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a tour of the facility's physical plant and in interview with the clinical supervisor, the facility failed to ensure that the stairways, hallways and exits were unobstructed.
The findings include:
The facility's physical plant was inspected on April 3, 2010 around 9:45 am. During this inspection it was found that the second floor exit by the nursing area was blocked with a wheel chair and a Christmas tree box. These items needed to be removed from the doorway in order to open it.
Additionally, the second exit on the second floor was very difficult to open and did not open completely. The inspector applied considerably force to open the door and it opened about 18 inches wide before it scraped the floor and would not open any further.
The clinical supervisor advised they were unaware that the door did not open completely.
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Plan of Correction
Items in question were removed from hallway while DAPL auditors were still there. The door in question was re-aligned at the same time. Director and maintenance personel will monitor these 2 items for compliance. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a tour of the facility's physical plant and in interview with the facility director, the facility failed to maintain a minimum of two exits on every floor that are separated by a minimum of fifteen feet.
The findings include:
The facility's physical plant was inspected on April 3, 2010 around 9:45 am. During this inspection it was found that the first floor of the facility had only one exit. When the inspectors asked the facility director to escort them to the second exit, they were advised it was only one exit on the first level.
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Plan of Correction
At next Board mtg, Director will discuss need for 2nd means of egress from 1st floor. It is expected that this will be unanimously approved and work will be started immediately with the target date of 7/31/10. Director will monitor for compliance and be in charge of obtaining bids for construction. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records and the program's policy and procedures, the facility failed to document a signed, dated, consent to treatment in eight of thirteen client records.
The findings include:
Thirteen outpatient client records were reviewed on April 13, 2010. A signed, dated, consent to treatment was required in thirteen client records. The program's policy states that a consent to treatment will be completed at intake. The facility did not document a consent to treatment in client records # 3, 5, 6, 8, 9, 11, 12, and 13.
Client # 3 was admitted on September 28, 2009. A signed consent to treatment was not found in the client file as of the date of inspection.
Client # 5 was admitted on October 23, 2009. A signed consent to treatment was not found in the client file as of the date of inspection.
Client # 6 was admitted on January 15, 2010. A signed consent to treatment was not found in the client file as of the date of inspection.
Client # 8 was admitted on November 15, 2009. A signed consent to treatment was not found in the client file as of the date of inspection.
Client # 9 was admitted on December 22, 2009. A signed consent to treatment was not found in the client file as of the date of inspection.
Client # 11 was admitted on June 30, 2009. A signed consent to treatment was not found in the client file as of the date of inspection.
Client # 12 was admitted on August 25, 2009. A signed consent to treatment was not found in the client file as of the date of inspection.
Client # 13 was admitted on September 24, 2009. A signed consent to treatment was not found in the client file as of the date of inspection.
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Plan of Correction
Director and Clin Sup pulled all intake packets and have added the consent to Tx that somehow was not included when last packet printed back in 2009. All pts currently there will be asked to sign a consent to treatment during their next individual session with their counselor. Clin Sup will monitor this for compliance and ensure that all future admissions sign one at the time of intake. |
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, the facility failed to document psychosocial evaluations that evaluated the client's problems and needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and/or failed to document the client's attitude toward treatment and/or the counselor's conclusions/impressions in nine of thirteen client records. In addition, the facility failed to document the date the psychosocial evaluation was completed in one of thirteen records reviewed.
The finding includes:
Thirteen client records were reviewed on April 13, 2010. Psychosocial evaluations were to be documented in thirteen client records. Nine records did not have biopsychosocial evaluations that evaluated the client's problems and needs, assets/strengths, support systems, coping mechanisms, and/or negative factors that might inhibit treatment evaluations, specifically records # 2, 4, 7, 8, 9, 10, 11, 12, and 13
Client record #2, did document a psychosocial evaluation, however the following areas were illegible: an evaluation of the client's problems and needs, negative factors that might inhibit treatment, the client's attitude toward treatment and the counselor's conclusions/impressions.
Client record # 4 failed to include an evaluation of the client's assets/strengths, support systems, and the counselor's conclusions/impressions.
Client record # 7 failed to include an evaluation of the client's problems and needs, assets/strengths, support systems, coping mechanisms, and negative factors that might inhibit treatment.
Client record # 8 did have a psychosocial evaluation but failed to date it, therefore the inspector could not determine if it had been timely.
Client records # 9 and 13 failed to include an evaluation of the client's coping mechanisms, problems and needs, assets/strengths, support systems, negative factors that might inhibit treatment, the client's attitude toward treatment and the counselor's conclusions/impressions.
Client record # 10 failed to include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, and the counselor's conclusions/impressions.
Client record # 11 failed to include an evaluation of the client's problems and needs assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, and the counselor's conclusions/impressions.
Client record # 12 failed to include an evaluation of the client's assets/strengths, coping mechanisms, negative factors that might inhibit treatment, and the counselor's conclusions/impressions.
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Plan of Correction
Clin Sup will perform an inservice training that will be mandatory for all clinical staff on the proper way to do a psychosocial eval and the time frames per DAPL and SOAR policies. This will be monitored through Clin Sup during regular chart audits done monthly and during weekly supervision as needed. |
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, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in nine of thirteen client records.
The findings include:
Thirteen client records were reviewed on April 13, 2010. The individual treatment and rehabilitation plans were required to document proposed types of support services in thirteen client records. The facility did not document proposed types of support services in client records # 1, 3, 4, 6, 7, 8, 9, 10, and 13.
Client # 1 was admitted on September 23, 2009. The individual treatment and rehabilitation plan was completed on October 23, 2009. There was no documentation of support services in the treatment plan.
Client # 3 was admitted on September 28, 2009. The individual treatment and rehabilitation plan was completed on October 28, 2009. There was no documentation of support services in the treatment plan.
Client # 4 was admitted on December 16, 2009. The individual treatment and rehabilitation plan was completed on January 16, 2010. There was no documentation of support services in the treatment plan.
Client # 6 was admitted on January 15, 2009. The individual treatment and rehabilitation plan was completed on February 15, 2010. There was no documentation of support services in the treatment plan.
Client # 7 was admitted on June 3, 2009. The individual treatment and rehabilitation plan was completed on July 3, 2009. There was no documentation of support services in the treatment plan.
Client # 8 was admitted on November 5, 2009. The individual treatment and rehabilitation plan was due on December 5, 2009. There was no documentation of a treatment and rehabilitation plan as of the date of inspection.
Client # 9 was admitted on December 22, 2009. The individual treatment and rehabilitation plan was completed on January 22, 2010. There was no documentation of support services in the treatment plan.
Client # 10 was admitted on April 6, 2009. The individual treatment and rehabilitation plan was completed on April, 1 2009. There was no documentation of support services in the treatment plan. Furthermore, the individual treatment and rehabilitation plan was completed before the biopsychosocial evaluation.
Client # 13 was admitted on September 24, 2009. The individual treatment and rehabilitation plan was completed on October 24, 2009. There was no documentation of support services in the treatment plan.
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Plan of Correction
Clin Sup will do an inservice that will be required for all clinical staff on the importance of including support services on treatment plans and wherever needed for patient care. Clin Sup will monitor this for compliance throughout the year during chart audits and weekly supervision. |
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
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plans, in seven of thirteen client records.
The findings include:
Thirteen client records were reviewed on April 13, 2010. Services and treatments are to be provided according to the recommendations in the individual treatment and rehabilitation plan. The facility did not document services according to the individual treatment plan in client records # 1, 2, 4, 6, 7, 9, and 13.
Client # 1 was admitted on September 23, 2009. The individual treatment and rehabilitation plan was completed on October 23, 2009. This treatment plan stated the client was to receive individual counseling sessions once a week and group counseling sessions three times a week. Client #1 has received individual counseling sessions once a month, with no documentation of group counseling. The last documented counseling session was on December 2, 2009. The record of service indicates the client had a session on March 11, 2010; however there was no documentation of this session in the progress notes.
Client # 2 was admitted on February 12, 2010. The individual treatment and rehabilitation plan was completed on March 12, 2010. This treatment plan stated the client was to receive individual counseling sessions once a week and group counseling sessions three times a week. Since entry into the outpatient program, client #2 has had only two documented individual sessions and no documentation of group sessions. The last documented counseling session was on March 18, 2010.
Client # 4 was admitted on December 16, 2009. The individual treatment and rehabilitation plan was completed on January 16, 2010. This treatment plan stated the client was to receive individual counseling sessions once a week and group counseling sessions three times a week. Since entry into the outpatient program, client #4 has had only two documented individual sessions and no documentation of group sessions. The last documented counseling session was on April 1, 2010.
Client # 6 was admitted on January 15, 2009. The individual treatment and rehabilitation plan was completed on February 15, 2010. This treatment plan stated the client was to receive individual counseling sessions once a week and group counseling sessions three times a week. Since entry into the outpatient program, client #6 has not had any documented group sessions.
Client # 7 was admitted on June 3, 2009 and discharged on February 11, 2010. The individual treatment and rehabilitation plan was completed on July 3, 2009. This treatment plan stated the client was to receive individual counseling sessions once a week and group counseling sessions three times a week. There were no documented group sessions during the eight months client # 7 was enrolled in the outpatient program.
Client # 9 was admitted on December 22, 2009 and discharged on March 8, 2010. The individual treatment and rehabilitation plan was completed on January 22, 2010. This treatment plan stated the client was to receive individual counseling sessions once a week and group counseling sessions three times a week. Only three group sessions were documented, during the eleven weeks client # 9 was enrolled in the outpatient program.
Client # 13 was admitted on September 24, 2009 and discharged on March 26, 2010. The individual treatment and rehabilitation plan was completed on October 24, 2009. The individual treatment and rehabilitation plan was completed on January 22, 2010. This treatment plan stated the client was to receive individual counseling sessions once a week and group counseling sessions three times a week. There were no documented group sessions during the six months client # 13 was enrolled in the outpatient program.
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Plan of Correction
Clin Sup will do an inservice for all cliical staff regarding this problem area. New form already developed that will be used in weekly supervision by Clin Sup for all clinical staff with a caseload. This will allow us to track services being delivered that are on the treatment plans for specific patients. Director will monitor Clin Sup to ensure compliance. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records and an interview with the facilit director, the facility failed to document case consultations within the ninety day time frame in three out of nine client records; additionally, the facility failed to update the dispositions of the case consultations in three of nine client records.
The findings include:
Thirteen client outpatient client records were reviewed on April 13, 2010. Per agency policy, case consultations shall be completed every ninety days. Case consultations were required in nine client records, specifically client records # 1, 2, 3, 4, 7, 10, 11, 12, and 13. The facility did not document a case consultation within the ninety day time frame in client records # 3, 4, and 5.
Client # 3 was admitted on September, 28, 2009. The case consultation was due by December 28, 2009. As of the date of inspection, there had not been a case consultation completed for client #3.
Client # 4 was admitted on December 16, 2009. The case consultation was due by March 18, 2010. As of the date of inspection, there had not been a case consultation completed for client #4.
Client # 5 was admitted on October 23, 2009. The case consultation was due by January 23, 2010. A case consultation had not been completed until March 28, 2010.
The facility failed to document an updated disposition in outpatient client records #7, 10, and 13.
Client # 7 was admitted on June 3, 2009. Case consultations had been completed for client #7 on September 3, 2009 and December 3, 2009. The dispositions of the case consultations read verbatim for both consultations.
Client # 10 was admitted on April 6, 2009. Case consultations had been completed for client #10 on July 6, 2009 and October 6, 2009. The dispositions of the case consultations read verbatim for both consultations.
Client # 13 was admitted on September 24, 2009. Case consultations had been completed for client #13 on October 24, 2009 and January 24, 2010. The dispositions of the case consultations read verbatim for both consultations.
The facility director confirmed that the case consultations had identical dispositions.
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Plan of Correction
Director to issue memo that will explain the time frames for case consults and the need for the consults to be individualized so that the same items are not being talked about every 3 months. Clin Sup will monitor during weekly supervision and during chart audits. Counselors will be asked to rewrite any case consult that needs to be changed. |
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 the review of client records, and the program ' s policy, the facility failed to document discharge summaries within seven days of discharge four of seven outpatient client records.
The findings include:
Thirteen client outpatient client records were reviewed on April 13, 2010. Discharge summaries were required in seven client records, specifically client records #7, 8, 9, 10, 11, 12, and 13. Per agency policy, discharge summaries shall be completed within one week of discharge. The facility did not document a discharge summary within the seven day time frame in client records # 7, 8, 9, and 13.
Client # 7 was admitted on June 3, 2009 and discharged on February 11, 2010. The discharge summary was due by February 18, 2010. A discharge summary had been documented in client record # 7, however it was undated and no way to determine if it had been completed in the specified time frame.
Client # 8 was admitted on November 5, 2009 and discharged on February 2, 2010. The discharge summary was due by February 9, 2010. A discharge summary had been documented in client record # 8, however it was undated and no way to determine if it had been completed in the specified time frame.
Client # 9 was admitted on December 22, 2009 and discharged on March 8, 2010. The discharge summary was due by March 15, 2010. A discharge summary had been documented in client record # 9, however it was undated and no way to determine if it had been completed in the specified time frame.
Client # 13 was admitted on September 24, 2009 and discharged on March 26, 2010. The discharge summary was due by April 2, 2010. As of the date of inspection, a discharge summary had not been completed for client #13.
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Plan of Correction
Director will issue memo and Clin Sup will do an inservice regarding the proper way and time frames that discharge summaries have to be done in. Clin Sup will monitor for compliance in weekly supervision and through chart audits. |