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 2, an abbreviated on-site inspection, conducted on December 3, 2020 through December 4, 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 were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
The facility failed to ensure that fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. The last annual inspection of all fire extinguishers in the facility occurred in October 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire extinguishers will be scheduled for a inspection within the next 30 days by the program director (1/21/21). Ongoing the program director shall ensure that the fire extinguishers are inspected annually with the fire alarm system during the month of October of each year. |
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
The project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seventeen client records reviewed.
Client #12 was admitted on May 1, 2020 and was discharged on July 28, 2020. On July 29, 2020, it was documented that there was communication between the facility and a probation agency; however, a signed informed and voluntary consent form was not documented in the client ' s record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will hold training on confidentiality and proper release formulation within the next 30 days (1/21/2021). The training will be mandatory for all clinical and intake staff. The training will cover the 5 domains of the 255.5 regulations, the 42 cfr proper release formulation. The training will review the need to indicate proper client and witness signatures, offering copies to clients, proper dates, and indicating the proper names of a person, agency or organization to which disclosure is to be made. Training certificates shall be kept in the HR binder of each employee to serve as proof of training. Post training, The Program director shall complete audits monthly on 10% of the charts to identify and issues with ROI's. If an issue is noted the clinical supervisor shall return the chart to the counselor for correction and it will be documented in a supervisor meeting. The audit process shall be ongoing. |
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
The project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a name of the person, agency or organization to whom disclosure is made in three of seventeen client records reviewed.
Client #1 was admitted on January 9, 2020 and was an active client at the time of the inspection. Two release of information forms, signed and dated on January 9, 2020, did not document a name of person, agency or organization to whom disclosures were to be made to.
Client #13 was admitted on October 13, 2020 and as a current client at the time of the inspection. Two release of information forms, signed and dated on October 14, 2020, did not document a name of person, agency or organization to whom disclosures were to be made to.
Client #16 was admitted on October 6, 2020 and was a current client at the time of the inspection. Two release of information forms, signed and dated on October 6, 2020, did not document a name of person, agency or organization to whom disclosures were to be made to.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will hold training on confidentiality and proper release formulation within the next 30 days (1/21/2021). The training will be mandatory for all clinical and intake staff. The training will cover the 5 domains of the 255.5 regulations, the 42 cfr proper release formulation. The training will review the need to indicate proper client and witness signatures, offering copies to clients, proper dates, and indicating the proper names of a person, agency or organization to which disclosure is to be made. Training certificates shall be kept in the HR binder of each employee to serve as proof of training. Post training, The Program director shall complete audits monthly on 10% of the charts to identify and issues with ROI's. If an issue is noted the clinical supervisor shall return the chart to the counselor for correction and it will be documented in a supervisor meeting. The audit process shall be ongoing. The program director shall resolve the ROI issue cited in client 1, 13, and 16 by 1/21/2021. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
The project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in three of three client records reviewed.
Client #2 was admitted on October 12, 2020 and was discharged on November 13, 2020. A release of information form to a probation agency, signed and dated by the client on October 19, 2020, allowed for the release of the biopsychosocial, thus exceeding the limits established by 4 Pa. Code 255.5.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will hold training on confidentiality and proper release formulation within the next 30 days (1/21/2021). The training will be mandatory for all clinical and intake staff. The training will cover the 5 domains of the 255.5 regulations, the 42 cfr proper release formulation. The training will review the need to indicate proper client and witness signatures, offering copies to clients, proper dates, and indicating the proper names of a person, agency or organization to which disclosure is to be made. Training certificates shall be kept in the HR binder of each employee to serve as proof of training. Post training, The Program director shall complete audits monthly on 10% of the charts to identify and issues with ROI's. If an issue is noted the clinical supervisor shall return the chart to the counselor for correction and it will be documented in a supervisor meeting. The audit process shall be ongoing. The program director shall resolve the ROI issue cited in client 1, 13, and 16 by 1/21/2021. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
The project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated witness signature in one of seventeen client records reviewed.
Client #12 was admitted on May 1, 2020 and was discharged on July 28, 2020. Two release of information forms to another treatment facility, signed and dated by the client on July 17, 2020, did not have a dated witness signature documented on the form
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will hold training on confidentiality and proper release formulation within the next 30 days (1/21/2021). The training will be mandatory for all clinical and intake staff. The training will cover the 5 domains of the 255.5 regulations, the 42 cfr proper release formulation. The training will review the need to indicate proper client and witness signatures, offering copies to clients, proper dates, and indicating the proper names of a person, agency or organization to which disclosure is to be made. Training certificates shall be kept in the HR binder of each employee to serve as proof of training. Post training, The Program director shall complete audits monthly on 10% of the charts to identify and issues with ROI's. If an issue is noted the clinical supervisor shall return the chart to the counselor for correction and it will be documented in a supervisor meeting. The audit process shall be ongoing. The program director shall resolve the ROI issue cited in client 1, 13, and 16 by 1/21/2021. |
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
The program failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, in two of fourteen patient records reviewed.
Patient #5 was admitted on July 21, 2020 and was a current patient at the time of the inspection. The patient was missing 1.5 of the 2.5 psychotherapy hours required for the month of November 2020.
Patient #10 was admitted on June 12, 2020 and was discharged on November 12, 2020. The patient was missing 2.5 of the 2.5 psychotherapy hours required for the months of September 2020 and October 2020.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
During COVID, Soar Corp will continue to utilize Telehealth as a measure to continue psychotherapy services for individual sessions. Group therapy sessions are not utilized during this period due to COVID restrictions. To document the inability to complete the therapy sessions due to COVID restrictions soar corp shall take the following steps. First the counselor shall place a non-billable note in the chart for each failed outreach call made for an agreed upon session time by phone. The counselors will place a non-billable note to chart reflecting any occurrences of a client changing, cancelling or ending a phone session early. On a monthly basis, the counselors shall place a monthly summery sheet in the chart to reflect significant gaps of service, non- compliance with treatment and any interventions implemented. The summery sheet will also reflect the number of and dates of missed therapy sessions. The program director shall be responsible for monitoring and compliance. The new system will be in effect within 30 days 1/21/2021 to allow notification of staff |
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
The program failed to document an annual physical examination which included an annual reevaluation by the narcotic treatment physician in one applicable patient record reviewed.
Patient #15 was admitted on August 20, 2019 and was a current patient at the time of the inspections. An initial physical exam was completed on August 20, 2019 and the next annual physical exam was to be completed no later than August 20, 2020; however, there was no documentation in the patient record of an annual physical exam at the time of the inspection.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
To address tracking due dates for the annual physical the following actions will be taken. By 1/21/21, a excel grid that highlights annual physicals within one week of the due date will be developed program director and regional director. Weekly, the physical grid shall be reviewed by the administrative assistant who is in charge of appointments, and upcoming appointments will be scheduled. The system will start to be used as of 1/21/21, and the program director shall be responsible for the management of the system. The missing physical referenced for patient 15 will be completed within the next 30 days (1/21/21). |
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
The program failed to document an annual evaluation of each patient's status that was completed by the patient's counselor and was reviewed, dated and signed by the medical director in two applicable patient records reviewed.
Patient #14 was admitted on April 7, 2010 and was a current patient at the time of the inspection. An annual evaluation was completed on April 7, 2019 and the next annual evaluation was due no later than April 7, 2020; however, there was no documentation in the patient record of an annual evaluation until November 23, 2020.
Patient #15 was admitted on August 20, 2019 and was a current patient at the time of the inspections. An annual evaluation was to be completed no later than August 20, 2020; however, there was no documentation in the patient record of an annual evaluation until November 23, 2020.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
To address the annual evaluation being late as noted for client 14 and 15the following actions will be taken. By 1/21/21, a excel data base chart check grid that highlights all due documentation within one week of the due date will be developed program director and regional director. The excel data base will show and highlight all of the due dates for treatment plans, case conferences, and annuals. The excel data base will be viewable to all counseling staff and supervisors, allowing staff to review and track daily. During supervision, the chart check grid shall be reviewed by the supervisor and plans to resolve outstanding work will be formulated and documented in a supervision note. The system will start to be used as of 1/21/21, and the clinical supervisor shall be responsible for the management of the system.
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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
The project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in eight of seventeen client records reviewed.
Client #1 was admitted on January 9, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan, completed on February 9, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the month of February and the weeks of March 1, 2020 through March 7, 2020, October 4, 2020 through October 10, 2020, October 11, 2020 through October 17, 2020 and October 18, 2020 through October 24, 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of April 2020, May 2020, June 2020, July 2020, August 2020, September 2020, October 2020 and November 2020.
Client #3 was admitted on January 6, 2020 and was discharged on March 17, 2020. A comprehensive treatment plan, completed on January 15, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of February 16, 2020 through February 22, 2020 and March 1, 2020 through March 7, 2020. Additionally, there was no documentation in the record that the client received a group counseling session for the week of February 2, 2020 through February 8, 2020.
Client #4 was admitted on July 14, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan, completed on August 14, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of November 8, 2020 through November 14, 2020 and November 15, 2020 through November 21, 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of August 2020, September 2020, October 2020 and November 2020.
Client #5 was admitted on July 21, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan, completed on August 21, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of November 1, 2020 through November 7, 2020 and November 15, 2020 through November 21, 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of August 2020, September 2020, October 2020 and November.
Client #8 was admitted on April 1, 2019 and was discharged on March 19, 2020. A treatment plan update, completed on November 15, 2019, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of January 12, 2020 through January 18, 2020 and January 26, 2020 through February 1, 2020. Additionally, there was no documentation in the record that the client received a group counseling session for the week of February 10, 2020 through February 16, 2020.
Client #10 was admitted on June 12, 2020 and was discharged on November 12, 2020. A comprehensive treatment plan, completed on July 15, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the months of September 2020 and October 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of June 2020, July 2020, August 2020, September 2020, October 2020 and November 2020.
Client #14 was admitted on April 7, 2019 and was a current client at the time of the inspection. A treatment plan update, completed on February 4, 2020, indicated that the client was to receive one individual counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of October 25, 2020 through October 31, 2020, November 8, 2020 through November 14, 2020 and November 22, 2020 through November 28, 2020.
Client #15 was admitted on August 20, 2019 and was a current client at the time of the inspection. A treatment plan update, completed on January 16, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of October 25, 2020 through October 31, 2020 and November 22, 2020 through November 28, 2020. Additionally, there was no documentation in the records indicating that the client received group counseling sessions for the months of April 2020, May 2020, June 2020, July 2020, August 2020, September 2020, October 2020 and November 2020.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of march of 2020, all patients have been excused from attending group therapy sessions as part of the emergency action plan for COVID that was submitted to DDAP. Individual sessions are being conducted by telehealth to make all attempts to provide counseling services according to the individual treatment plan. To document difficulties in meeting this domain soar shall take the following actions. First, the mention of group therapy sessions will be removed from all treatment plans as of 12/28/20 and shall not be referenced as an approved counseling session on the plans till the COVID restrictions are lifted. Second, to document any difficulties in completing individual therapy sessions, the counselor shall place a non-billable note in the chart for each failed outreach call sessions by phone. The counselors will place a non-billable note to chart reflecting any occurrences of a client changing, cancelling or ending a phone session early. On a monthly basis, the counselors shall place a monthly summery sheet in the chart to reflect significant gaps of service, non- compliance with treatment plans and being excused from counseling sessions. The summery sheet will also reflect the number and dates of missed therapy sessions. The regional Project Director shall issue an instructional Memo to all clinical staff of the facility within 30 days 1.15.21 to notify the staff of the new system that must be followed. Post notification, the program director shall be responsible for ensuring the monthly summery sheets and non-billable notes are placed in the charts by the counseling staff. |