INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on July 30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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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704.11(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 and the facility-submitted Staffing Requirement Facility Summary Report, the facility failed to ensure that all employees received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe in two of four personnel records reviewed.
Employee #3 was hired as a counselor on April 3, 2019 and was due to have the communicable disease trainings no later than April 3, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training.
Employee #4 was hired as a counselor on March 24, 2019 and was due to have the communicable disease trainings no later than March 24, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee 3 and Employee 4 both were scheduled for the HIV training for 4/23/2020 within DDAP's TMS system, but due to COVID-19 the trainings were cancelled. It is acknowledged that the employees referenced would of completed the HIV training past the established due date per regulation. The program director and the employees referenced shall check the TMS system every 2 weeks to locate and register for a local HIV training and shall aim to complete this training within the next 60 days (10/1/2020). Ongoing, within the first 30 days of employment, the program director shall meet with all new employees to assist them in locating and scheduling all required trainings. The program director shall review training completions to ensure they are completed within the first year of hire. The program director shall document the scheduling, review and training recommendations within the supervision notes of the employee. The review of the trainings shall be ongoing by the program director |
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 project 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.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Soar Corp's CEO will request that the Board of Directors approve an authorization for an audit to be completed for the Oct 1, 2018 to Sept 30th 2019 time period. The request for the audit shall be made at the next board meeting in 60 days. The CEO will be responsible in facilitating and arranging for an independent auditor within the next 120 days (11/30/2020). Proof of completion shall be supplied as needed to the regional project director to meet the standard. Ongoing the CEO will make request for the approval of an auditor annually in the first quarter of each year and shall supply a copy to the Regional Project Director. |