INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on September 13-17, 2021 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that the facility was kept in good repair. There was a leak in the mechanical equipment closet located in Suite 1. There was water dripping inside the closet resulting in a puddle on the floor. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A private business located above Soar's office froze their HVAC unit resulting in water dripping from their unit to the closet of Soar. As of 9/29/21 Soar's maintenance staff will check this area identified weekly to ensure it is free of hazards and the program director will be responsible to ensure the action is implemented. If a hazard is observed, the management team shall report the issue to the program director. The program director shall be responsible to report any issue to the building owner for immediate correction. The program director shall ensure the process is ongoing |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that there were no heaters that were not permanently mounted or installed. A space heater was discovered in a counselor's office located in the hallway to the left of the elevator on the second floorThis finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The space heater cited in the one counselor's office was moved during the onsite inspection. The regional project director shall issue an instructional member to all staff by e-mail to instructing them that the use of space heaters or having space heaters in an office shall not be permitted on the grounds of the facility. The instructional member shall be sent by 10/8/21. Ongoing Soar's maintenance staff will check facility monthly to ensure it is free of this hazard and shall be remove as needed. |
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 a review of the pre-submission documentation and an interview with the Project Director, the facility failed to provide documentation of an annual audit. Per the plan of correction submitted June 8, 2021, the Chief Executive Officer was to identify a Certified Public Accountant to complete the audit of last year's fiscal information by June 30, 2021. Then the CEO and the Board of Directors were to have the fiscal year audit, identified as October 2019 to September 2020, completed by August 30, 2021. The Chief Executive Officer was identified as the person responsible for the completion of this plan of correction.Fiscal Management has been cited in the previous five inspections dated April 27, 2021, August 24, 2020, October 4, 2019, January 8, 2019 and January 16, 2018.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
An audit engagement letter and a statement from the owner was given to the DDAP reviewer at the time of the onsite inspection. The audit is expected to be completed by 10/31/2021. The audit will be forwarded to DDAP once the results are received by Soar and prior to the expiration of our current license. The CEO will be responsible to ensure that the audit is completed within the time outlined |
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 the review of the physician timesheets for the months of May, June, July and August 2019, the facility failed to provide at least one hour of physician time a week, on site for every ten patients during the weeks of May 9-15, 2021 and May 16-22, 2021.During the week of May 9-15, 2021, the patient census was 490 patients. The facility was required to provide at least 49 physician hours. There were 41.5 physician hours documented.During the week of May 16-22, 2021, the patient census was 488 patients. The facility was required to provide at least 48.8 physician hours. There were 35.5 physician hours documented.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 10/1/21, Soar's Quality Assurance staff will be responsible to schedule and coordinate MD coverage for a MD's vacation. The QA staff will post the coverage schedule by e-mailing staff. Ongoing, Soar's Quality Assurance staff will review the MD hours and time off request monthly to ensure compliance with regulation is kept. Identified issues shall be reported to the program director for correction. The Program Director will oversee the process to ensure completion. |
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 fourteen patient records, the facility failed to provide each patient with an average of 2.5 hours of psychotherapy per month during the patient ' s first 2 years of treatment in five out of eight applicable records. Patient # 1 was admitted on November 13, 2020 and was an active patient at the time of the inspection. During the month of May 2021, the patient had 1 hour of individual therapy and 0 hours of group therapy. In June 2021, the patient had 1 hour of individual therapy and 0 hours of group therapy. In July 2021, the patient had 0 hours of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods. Patient # 4 was admitted on June 16, 2020 and was an active patient at the time of the inspection. During the month of May 2021, the patient had 1 hour of individual therapy and 0 hours of group therapy. In June 2021, the patient had 1 hour of individual therapy and 0 hours of group therapy. In July 2021, the patient had 0 hours of individual therapy and 0 hours of group therapy. In August 2021, the Patient had 0 hours of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods. Patient # 6 was admitted on July 21, 2021 and was an active patient at the time of the inspection. During the month of July 2021, the patient had 0 hours of individual therapy and 0 hours of group therapy. In August 2021, the patient had 15 minutes of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods. Patient # 9 was admitted on March 30, 2020 and was an active patient at the time of the inspection. During the month of May 2021, the patient had 2 hours of individual therapy and 0 hours of group therapy. In June 2021, the patient had 1 hour of individual therapy and 0 hours of group therapy. In July 2021, the patient had 2 hours of individual therapy and 0 hours of group therapy. In August 2021, the patient had 1 hour of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.Patient #12 was admitted on June 17, 2020 and was an active patient at the time of the inspection. During the month of May 2021, the patient had 20 minutes of individual therapy and 0 hours of group therapy. In June 2021, the patient had 0 hours of individual therapy and 0 hours of group therapy. In July 2021, the patient had 0 hours of individual therapy and 0 hours of group therapy. In August 2021, the patient had 0 hours of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The following process will be in effect as of 10/1/21 and shall be ongoing to address the deficiency noted. Every two weeks, the clinical supervisor will now run the "patients not counseled report" to identify patients who have not completed the required psychotherapy hour or hours as required by regulation. The clinical supervisor and / or counselor shall place the patient on hold for treatment completion. Continued non-compliance with, patient no shows for, or cancellations of scheduled treatment sessions shall be documented on a non-billable note by the primary counselor. The non-billable notes shall be kept in the patient's EMR and serve as proof that attempts for sessions were made by staff. The process will be monitored by the program director to ensure completion. |
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 fourteen patient records, the facility failed to provide each patient with at least one hour per month of group or individual services during the third and fourth year of treatment in one of three applicable records.Patient # 14 was admitted on December 11, 2017 and discharged on August 16, 2021. During the month of May 2021, the patient had 0 hours of individual therapy and 0 hours of group therapy. In June 2021, the patient had 0 hours of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The following process will be in effect as of 10/1/21 and shall be ongoing to address the deficiency noted. Every two weeks, the clinical supervisor will now run the "patients not counseled report" to identify patients who have not completed the required psychotherapy hour or hours as required by regulation. The clinical supervisor and / or counselor shall place the patient on hold for treatment completion. Continued non-compliance with, patient no shows for, or cancellations of scheduled treatment sessions shall be documented on a non-billable note by the primary counselor. The non-billable notes shall be kept in the patient's EMR and serve as proof that attempts for sessions were made by staff. The process will be monitored by the program director to ensure completion. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of fourteen patient records, after four years of treatment, the facility failed to provide each patient with at least one hour of group or individual services every two months in one of three applicable records.Patient #13 was admitted on June 25, 2014 and was an active patient at the time of the inspection. During the month of June 2021, the patient had 0 hours of individual therapy and 0 hours of group therapy. In July 2021, the patient had 0 hours of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The following process will be in effect as of 10/1/21 and shall be ongoing to address the deficiency noted. Every two weeks, the clinical supervisor will now run the "patients not counseled report" to identify patients who have not completed the required psychotherapy hour or hours as required by regulation. The clinical supervisor and / or counselor shall place the patient on hold for treatment completion. Continued non-compliance with, patient no shows for, or cancellations of scheduled treatment sessions shall be documented on a non-billable note by the primary counselor. The non-billable notes shall be kept in the patient's EMR and serve as proof that attempts for sessions were made by staff. The process will be monitored by the program director to ensure completion. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on a review of patient records, the facility failed to provide a complete patient record, which is to include case consultation notes, in two out fourteen records reviewed.Patient # 4 was admitted on June 16, 2020 and was still active at the time of the inspection. Documentation for the case consultation due June 16, 2021 was missing from the chart.Patient # 11 was admitted on April 30, 2021 and was still active at the time of the inspection. Documentation for the case consultation due July 30, 2021 was missing from the chart.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 9/27/21, an EMR Tracking Grid has been established for the medical and clinical staff to track case conferences, clinical annuals, and bloodwork and ppd test. Weekly, the clinical supervisors will review the EMR Tracking Grid to identify clinical annual evaluations that are outstanding or need to be completed by a counselor and shall address this in the clinical supervision meetings. At the end of each month, the Quality assurance assistant will audit clinical annual evaluations and findings will be reported to the clinical supervisor for correction. The program director shall monitor for completion and this process will be ongoing. The clinical supervisor shall complete the missing reviewed noted in the inspection for patient 4 and 11 by 10/8/21 |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation within thirty days of a patient's admission date in one out of fourteen records reviewed. Their policy states this should be completed within thirty days.Patient # 6 as admitted on July 21, 2021 and was still active at the time of this inspection. The psychosocial evaluation was completed on September 10, 2021.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 9/1/21, all psychosocial evaluations, will be completed electronically, at the time of the initial assessment. AS of 10/1/21, Soar's quality assurance staff have established an internal audit system for new admissions. All intake records will be audited, by the quality assurance staff within 7 days of admission to the program and the deficiencies found are shall be corrected by the clinical supervisors within 7 days. The internal audit system to verify intake and psychosocial evaluation documentation is completed will be ongoing and monitored by the program director |
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 fourteen patient records, the facility failed to document an annual clinical evaluation of the patient in two of ten applicable patient records.Patient # 3 was admitted on July 11, 2018 and was discharged on July 20, 2021. The most recent annual evaluation was due no later than July 11, 2021 however, it was not documented as of the date of the inspection.Patient # 4 as admitted on June 16, 2020 and was still active at the time of the inspection. An annual evaluation was due no later than June 16, 2021 however, it was not documented as of the date of this inspection.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 9/27/21, an EMR Tracking Grid has been established for the medical and clinical staff to track case conferences, clinical annuals, and bloodwork and ppd test. Weekly, the clinical supervisors will review the EMR Tracking Grid to identify clinical annual evaluations that are outstanding or need to be completed by a counselor and shall address this in the clinical supervision meetings. At the end of each month, the Quality assurance assistant will audit clinical annual evaluations and findings will be reported to the clinical supervisor for correction. The program director shall monitor for completion and this process will be ongoing. The clinical supervisor shall complete the missing review noted in the inspection for patient 4 by 10/8/21 |