INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 12, 2010 through April 13, 2010 licensure renewal inspection. The follow-up inspection was conducted on September 27, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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
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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 since the last inspection dated April 12-13, 2010.
The findings were:
Administrative documentation was reviewed on September 27, 2010. The failed to submit, upon request, an annual report for the 2008-2009 fiscal year. An interview with the Project Director on September 27, 2010 confirmed that the annual report for the 2008-2009 fiscal year had not been completed since the last inspection.
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Plan of Correction
All policies have been changed to reflect a calendar year. Annual report for 2010 will be prepared by Project Director and Soar Board in timely manner. Ad will also be placed in appropriate venue for general public to inform that one can be obtained on site. Annual report for 2009 will be prepared by Project Director by 11/30/2010 and made available. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed maintain a data collection and record-keeping system that allows for the efficient retrieval of data needed to measure the projects performance to measure the project's performance in relationship to its stated goals and objectives.
The findings include:
A list of 14 client records to be reviewed was presented to the facility director on September 27, 2010. The facility was unable to present client record #8 to the Licensing Specialist for review.
When facility director was asked about client #8's record, the facility director stated that the record could not be found. The facility director and staff looked for the record during the follow-up inspection and still could not retrieve the record.
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Plan of Correction
Clinical Supervisor and Director will develop a new sign-out form for all staffs use when a pt chart is removed from the chart room. Clinical Supervisor will monitor for compliance throughout the year and will keep all filled out sign-out forms in file for up to one year.
Counselor who last had chart and could not produce it when requested is no longer employed by Soar. |
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 follow-up inspection and an interview with the facility director, the facility failed to maintain a minimum of two exits on every floor that is separated by a minimum of fifteen feet.
The findings include:
The follow-up inspection took place on September 27, 2010. The first floor of the treatment facility still only has one exit. During the interview with the facility director he informed me that they are looking to increase capacity and when it is approved the other part of the first floor will be opened and that is where the second exit is located, but at this present time they do not have a second exit and one will be put in.
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Plan of Correction
Project Director called meeting with owner and approval granted to put in 2nd means of egress on first floor. Construction company already on site due to flood and work is slated to begin the week of 10/27/2010. Projest Director will monitor for compliance. |
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 four of eleven client records.
The findings include:
Eleven client records were reviewed on September 27, 2010 for a signed, dated, consent to treatment. 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 # 2, 7, 8 and 11.
Client # 2 was admitted on August 2, 2010. A signed consent to treatment was not found in the client file as of the date of inspection.
Client # 7 was admitted on September 1, 2010. A signed consent to treatment was not found in the client file as of the date of inspection.
Client # 11 was admitted on July 7, 2010. A signed consent to treatment was not found in the client file as of the date of inspection.
Client # 8 was admitted on June 10, 2010. A signed consent to treatment was not found in the client file as of the date of inspection. As of to date record could not be found during the inspection.
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Plan of Correction
Clinical Supervisor will provide additional training for intake coordinator. Memo on consent forms given to all clinical staff by Clinical supervisor directing how and when one is needed and will monitor through quarterly chart reviews. Program Director to provide additional monitoring as needed. |
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 to include a composite picture, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and/or the counselor conclusions/impressions in eleven of eleven client records.
The finding includes:
Eleven client records were reviewed on September 27, 2010 for psychosocial evaluations.
Client record #1 failed to document the client ' s support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
Client records #4, 5, 6, 9 and 10 failed to document the client ' s assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
Client records #2, 3, 7, 8 and 11 failed to document the client ' s composite picture, the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
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Plan of Correction
Program Director to perform in-service on proper way to do a psychsocial evaluation that does not simply repeat history information. Clinical Supervisor to monitor in supervision sessions with counselors throughout the year. |
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 five of eleven records reviewed.
The findings include:
Eleven client records were reviewed on September 27, 2010 to determine if the types of support services were included in the individual treatment and rehabilitation plans. The facility failed to document proposed types of support services in five of eleven client records, # 1, 2, 6, 8 and 10.
Client # 1 was admitted on August 5, 2010. The individual treatment and rehabilitation plan was not documented in record reviewed.
Client # 2 was admitted on August 2, 2010. The individual treatment and rehabilitation plan was completed on August 31, 2010. There was no documentation of support services in the treatment plan.
Client # 6 was admitted on July 6, 2010. The individual treatment and rehabilitation plan was completed on August 6, 2010. There was no documentation of support services in the treatment plan.
Client # 8 was admitted on June 10, 2010. The individual treatment and rehabilitation plan could not be reviewed because record could not be located during the follow-up inspection.
Client # 10 was admitted on June 15, 2009. The individual treatment and rehabilitation plan was not documented in record reviewed.
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Plan of Correction
Program Director and/or Clinical Supervisor to perform in-service on proper way to do paperwork regarding treatment planning. Additionally, Clin Sup to identify where additional trainings needed for individual counselors and place on annual training plan for individual Counselors. |
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, the facility failed to document case consultations within ninety days ads per facility policy in five of fourteen client records reviewed.
The findings include:
Five client records requiring case consultations were reviewed on September 27, 2010. Per agency policy, case consultations shall be completed every ninety days. Case consultations were required in client records # 5, 8, 9, 12 and 14. The facility did not document a case consultation within the ninety day time frame in client records # 5, 8, 9, 12 and 14.
Client # 5 was admitted on June 22, 2010. The case consultation was due by September 22, 2010. As of the date of inspection, there had not been a case consultation completed for client #5.
Client # 8 was admitted on June 10, 2010. The case consultation was due by September 10, 2010. Client record #8 was not found during the licensing inspection.
Client # 9 was admitted on May 19, 2010. The case consultation was due by August 19, 2010. As of the date of inspection, there had not been a case consultation completed for client #9.
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Client # 12 was admitted on March 6, 2010. The case consultation was due by June 6, 2010. As of the date of inspection, there had not been a case consultation completed for client #12.
Client # 14 was admitted on March 23, 2010. The case consultation was due by June 23, 2010. As of the date of inspection, there had not been a case consultation completed for client #14.
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Plan of Correction
Clinical Supervisor will provide inservice training on proper way and time frames regarding case consultations. Clin Sup to monitor for compliance in supervision and through quarterly chart reviews. |
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 in four of six client records.
The findings include:
Six client records requiring discharge summaries were reviewed on September 27, 2010. Discharge summaries were required in six client records #9, 10, 11, 12, 13 and 14. 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 #9, 10, 12 and 13.
Client # 9 was admitted on May 19, 2010 and discharged on September 7, 2010. The discharge summary was due by September 14, 2010. As of the date of inspection, a discharge summary had not been completed for client #9.
Client # 10 was admitted on June 15, 2010 and discharged on September 7, 2010. The discharge summary was due by September 14, 2010. As of the date of inspection, a discharge summary had not been completed for client #10.
Client # 12 was admitted on March 16, 2010 and discharged on July 22, 2010. The discharge summary was due by July 29, 2010. As of the date of inspection, a discharge summary had not been completed for client #12.
Client # 13 was admitted on October 23, 2009 and discharged on July 26, 2010. The discharge summary was due by August 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
Clinical Supervisor will perform in-service training for all clinical staff on how to do a discharge summary. Clin Sup will also monitor throughout the year in weekly supervision sessions with Counselors. |