INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 21, 2023 through September 22, 2023 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 - Warminster 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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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
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven applicable client records reviewed.
Client # 2 was admitted on January 24, 2023 and was still active at the time of the inspection. There was evidence of a disclosure to another treatment provider on January 25, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director shall offer an internal training on the topic of releases and confidentiality by 11/17/2023. Proof of the training shall be placed in the employees HR file in the form of a certificate. The training will cover proper release formulation, the need to complete an informed and voluntary consent prior to the disclosure of information and the review of the 42CFR regulations. To ensure compliance the program director and qi staff shall audit a sample of charts monthly to ensure the procedure above is followed. The program director shall address ongoing issues in this area during the supervision process. Patient 2 will be asked to sign a release for the treatment provider noted by 11/17/2023. This process will start as of 11/17/2023 and shall 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 two of seven applicable patient records reviewed.
Patient # 2 was admitted on January 24, 2023 and was still active at the time of the inspection. There was no documentation that a random urinalysis was conducted during the month of July 2023.
Patient # 4 was admitted on May 7, 2019 and was discharged on August 21, 2023. There was no documentation that a random urinalysis was conducted during the month of April 2023.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
As of 11/17/23, the nursing manager will run a "patient without a uds report" from the EMR system twice a month to identify the patients who have not completed the minimum UDS screening requirements. Patient identified by this method shall be placed on hold to complete a sample. Patients who refuse to complete the screenings shall have a Non-billable medical note placed in their emr record to indicate the attempt and refusal to complete. To ensure compliance at the end of each month, the qi staff shall run "patient without a uds report" and audit the patient's chart for a nonbillable note. A chart lacking a nonbillable note shall be sent to the nursing manager for correction. The process will be ongoing as of 11/17/23 |
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
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in one of four applicable patient records reviewed.
Patient # 5 was admitted on April 6, 2021 and was discharged on April 20, 2023. The record of service and progress notes documented that during the month of November 2022 there was 1 hour of psychotherapy provided to the client. During the month of December 2022 there was 1.5 hours of psychotherapy provided to the client. During the months of January and February 2023 there was 0 hours of psychotherapy provided to the patient. During the month of March 2023 there was 30 minutes of psychotherapy provided to the patient.
This is a repeat citation from the November 7, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within the next 30 days (11/18/23) a formal training will be completed by the Regional Director that will focus on the psychotherapy hours with the clinical staff of the program. The training will focus on reviewing the agency policy on the psychotherapy hours and the state regulations for the psychotherapy hours. The training will also focus on Managing patient who are non-compliant with attending sessions and the steps to document session non-compliance within the patient's EMR. Post training, the program director / clinical supervisor will run a "patient not counseled report" from the EMR system weekly to identify the patients who have missed therapy sessions. Patient identified shall be placed on hold to complete a session by the program director / clinical supervisor. Patients who refuse to complete a therapy session shall have a Non-billable note placed in their emr record to indicate the attempt and refusal to complete. To ensure compliance at the end of each month, the qi staff shall run "patient not counseled report" and audit the patient's chart for a nonbillable note. A chart lacking a nonbillable note shall be sent to the program director / supervisor for correction. Whole plan will be in effect within 30 days (11/18/23). |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide at least 1 hour per month of group or individual psychotherapy per month during the third and fourth year of treatment in one of two applicable patient records reviewed.
Patient # 4 was admitted on May 7, 2019 and was discharged on August 21, 2023. The record of service and progress notes documented that during the months of February and March 2023, there was 0 hours of psychotherapy provided to the patient.
This is a repeat citation from the November 7, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within the next 30 days (11/18/23) a formal training will be completed by the Regional Director that will focus on the psychotherapy hours with the clinical staff of the program. The training will focus on reviewing the agency policy on the psychotherapy hours and the state regulations for the psychotherapy hours. The training will also focus on Managing patient who are non-compliant with attending sessions and the steps to document session non-compliance within the patient's EMR. Post training, the program director / clinical supervisor will run a "patient not counseled report" from the EMR system weekly to identify the patients who have missed therapy sessions. Patient identified shall be placed on hold to complete a session by the program director / clinical supervisor. Patients who refuse to complete a therapy session shall have a Non-billable note placed in their emr record to indicate the attempt and refusal to complete. To ensure compliance at the end of each month, the qi staff shall run "patient not counseled report" and audit the patient's chart for a nonbillable note. A chart lacking a nonbillable note shall be sent to the program director / supervisor for correction. Whole plan will be in effect within 30 days (11/18/23). |
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 two applicable patient records reviewed.
Patient #1 was admitted on June 15, 2023 and was still active at the time of the inspection. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date the initial dose was given.
This is a repeat citation from the November 7, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An instructional memo will be sent out by the regional project director regarding patient transfers. The memo will state that the intake counselor will be responsible to fill out Soar's dose verification form and document the date of the admission of the patient and the date of the initial dose given on the form. The Dose verification form will be emailed to the contact person of the transferring narcotic treatment program at the time of admission. The email sent shall serve as the document in writing that the transferring program has been notified of the admission. A copy of the email will be scanned into the patients' emr to serve as proof. Monthly, the QI department will audit all new intakes to ensure the plan is followed and documentation is noted in the chart. Occurrence of missing documents shall be sent to the program director for correction. Process will be start as of 11/18/23 and shall 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 three of three applicable patient records reviewed.
Patient # 3 was admitted on May 17, 2019 and was still active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on May 26, 2023; however, the evaluation was reviewed, dated, and signed by the narcotic treatment physician, not the medical director.
Patient # 4 was admitted on May 7, 2019 and was discharged on August 21, 2023. The annual evaluation of the patient's status was completed by the counselor on May 17, 2023; however, the evaluation was reviewed, dated, and signed by the narcotic treatment physician, not the medical director.
Patient # 6 was admitted on March 8, 2022 and was discharged on April 11, 2023. The annual evaluation of the patient's status was completed by the counselor on March 8, 2023; however, the evaluation was reviewed, dated, and signed by the narcotic treatment physician, not the medical director.
This is a repeat citation from the November 7, 2022 annual licensing inspection.
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 (11/18/2023). The memo will also state that if a narcotic physician is covering the medical director's time off, they will not sign a clinical annual review. The memo will state that the clinical annual must be left for the medical director to sign even if the document will then be signed late by the provider. In an effort to ensure compliance, the QA department will audit clinical annual evaluations for completion, and appropriate signatures. Audit will begin by 11/18/2023 and shall be monitored for completion nu the QI manager |