INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 8, 2022 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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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 provide the required one hour of onsite physician time per week for every ten patients in 16 weeks reviewed.
During the work week of July 25 - 31, 2022, the patient census was 456. The facility was required to provide at least 45 physician hours. There were only 38 physician hours documented.
During the week of August 8 - 14, 2022 the patient census was 451. The facility was required to provide at least 45 physician hours. There were only 42.50 physician hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 10/3/22, the agency has hired an additional full time APRN. She will be working in all SOAR locations. As of result of this hire, the Medical Doctor hours for the Philadelphia site will be increased to a total 24 hours per week. The APRN hours will be increased to total of 40 hours a week. a total of 64 MD hours will be available weekly. This is effective as of 11/14/22 and the ratio shall be monitored by the QI director to ensure compliance |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the facility failed to physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and 709.28 (relating to confidentiality).
Patient #1 was admitted on September 27, 2022 and was active at the time of inspection. There was another patient's consent to release information form to a treatment provider included in this patient's record. Additionally, there was another patient's orientation form included in this patient's record.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
To ensure a document is not misfiled and placed in the incorrect patient filed the following action will take place. First the QI department and the program director shall audit a total of 10% of the active patient files per quarter to identify missing or misfiled items. The Program Director will now audit all new admissions, within 7 days to identify missing or misfiled items. Any occurrence of a misfiled or missing document shall be corrected by the program director. Patient 1 identified in the report shall have audit completed to correct the finding by 12/1/2022. This process will begin on 12/1/2022 and will be ongoing. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to complete and document a random urinalysis, for each patient, at least monthly in one of seven patient records reviewed.
Patient #6 was admitted on January 24, 2014 and was discharged on July 19, 2022. There was no documentation that a random urinalysis was conducted during the month of May 2022.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 12/1/22, The Director of Nursing will run a "patient without a UDS report" from the EMR twice a month to identify the patients who have not completed the minimum urine drug screen requirements. Patients identified by this method shall be placed on hold to do so. Patients who refuse to complete a screening shall have a Non-billable note placed in their EMR record to document as such, and serve as proof that attempts for screening were made by staff. The process will be ongoing and will be monitored by the Director of Nursing to ensure completion. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient records reviewed.
Patient #5 was admitted on August 24, 2022 and was discharged on October 15, 2022. There was no documentation in the record that the transferring narcotic treatment program was notified of the date of admission and the date the initial dose was given.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All transfers-in will be monitored weekly by the program director. The regional project director shall send an instructional memo to the Intake Staff outlining the need to send all first dose verifications to the sending program. The Program Director will now audit all new admissions, within 7 days to ensure compliance. This process will begin on 11/21/22 and will be ongoing. |
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 facility 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 three applicable patient records reviewed.
Patient #2 was admitted on October 16, 2017 and was active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on October 20, 2022; however, the evaluation was not reviewed, dated, and signed by the medical director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director will send an instructional memo to all medical and clinical staff, outlining the appropriate process for completing a clinical annual evaluation. The memo will state the Medical Director must sign all clinical annual evaluations. The memo will be sent within 30 days (12/15/22). In an effort to ensure compliance, the QA department will audit clinical annual evaluations for completion, and appropriate signatures. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in three of seven client records reviewed.
Client #3 was admitted on July 2, 2021 and was active at the time of inspection. A treatment plan update was completed on February 9, 2022 and the next update was due no later than April 9, 2022; however, the update was completed on May 22, 2022. Additionally, a treatment plan update was completed on June 30, 2022 and the next update was due no later than August 30, 2022; however, the update was completed on September 13, 2022.
Client #4 was admitted on March 4, 2022 and was discharged on October 4, 2022. A treatment plan update was completed on June 16, 2022 and the next update was due no later than August 16, 2022; however, the update was completed on August 22, 2022.
Client #7 was admitted on March 10, 2022 and was discharged on November 1, 2022. A treatment plan update was completed on June 3, 2022 and the next update was due no later than August 3, 2022; however, the update was completed on October 4, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director/Clinical Supervisor will run the tx plan due report, weekly. The Program Director/Clinical Supervisor will email this report to the counselors. The Program Director/Clinical Supervisor will run the tx plan due report at the end of the week to ensure compliance. Any deficiencies will be reviewed in clinical supervision. This is will be in effect beginning 11/21/22. |