INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 11, 2025 through August 12, 2025, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of two applicable personnel records reviewed.
Employee # 3 was hired as a counselor assistant on May 29, 2024 and was promoted to a counselor on May 29, 2025. There was documentation the HIV/AIDS training was completed. The TB/STD training was to be completed no later than May 29, 2025; however, there was no documentation indicating the training was completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective August 15, 2025, a new shared electronic document drive has been created to track staff training requirements. The Regional Director has shared this document with all Program Directors and Clinical Supervisors. During scheduled supervision sessions, supervisors will now review required trainings with their staff, offering assistance in locating necessary courses as needed. Supervisors will document the outcomes of these discussions in the supervision notes. Additionally, the HR Assistant will conduct a monthly review of the training grid. Within 30 days of this notice (August 15, 2025), the HR Assistant will send the first email to all staff, outlining their current training hours and required courses. The employee mentioned in the report is expected to schedule the specified training within 60 days of receiving this email. The Program Director will monitor the employee's progress to ensure completion. |
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.
|
Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed.
The physical plant inspection was conducted on August 12, 2025 at approximately 11:05 AM and there was a space heater found in a counseling office.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As of August 28, 2025, the regional project director has issued a memo by email regarding individual space heaters in offices. To ensure compliance with this new instruction, staff are no longer authorized to have personal space heaters in their offices and any other location within the facility. The program director will be conducting monthly checks of all offices and workspaces to ensure adherence to this policy. The space heater mentioned in the report has already been removed by the counselor. |
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.
|
Observations
Based on an administrative review, the facility 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.
At the time of the inspection, there was no financial audit completed for the facility fiscal year ending June 30, 2024.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Within the next 90 days, Soar Corp will contract with an independent certified public accountant to perform an annual financial audit for the project's fiscal year ending June 30, 2024. The CEO of Soar is responsible for this process, with the immediate goal of securing a completed audit within the 90-day timeframe. The CEO will also ensure all future audits are completed within 90 days of their respective fiscal year-ends to maintain compliance with all relevant standards.
|
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.
|
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 two of seven client records reviewed.
Client # 1 was admitted on July 3, 2025 and was still active at the time of the inspection. There was evidence of a disclosure to another treatment provider on August 8, 2025; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 4 was admitted on February 25, 2025 and was discharged on July 8, 2025. There was evidence of disclosures to several other treatment providers on March 3, 2025; however, there were no consent to release information forms signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By October 1, 2025, the Program Director will provide an internal training on releases and confidentiality. The training will cover proper release formulation, the need for informed and voluntary consent before disclosing information, and a review of 42 CFR regulations. It will also emphasize that specific names of emergency contacts and other individuals must be listed on a signed release of information (ROI). Additionally, the training will address the importance of obtaining consent before sharing transfer-in, transfer-out, and dosing information. Finally, the Program Director and the administrative assistant will conduct a monthly audit of a sample of charts to ensure this procedure is followed. The Program Director will address any ongoing issues during supervision sessions, and proof of the training will be placed in each employee's HR file in the form of a certificate |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of the facility's August 2024 through August 2025 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police and/or ambulance personnel at the facility.
There was a reportable incident, which occurred on July 8, 2025, and was not reported to the Department until August 11, 2025.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
A instruction memo was issued on 8/28/2025 by email regarding the updated protocol for incident reporting. Staff was instructed that all incident reports must be submitted to their immediate supervisor at the time of a occurrence. Staff were also instructed that they must also send an email notification about the incident to both the Program Director and the Regional Director. Incident reports must be filed with DDAP and relevant funding sources within 24 hours of the incident. The Program Director will be responsible for filing the reports with DDAP, and the Regional Director will verify that these reports have been filed. The process will start 8/28/2025 and be ongoing |
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
|
Observations
Based on an administrative review, the facility failed to ensure that narcotic treatment physician services were provided at least 1 hour per week onsite for every ten patients.
During the week of May 13, 2025 through May 19, 2025, the patient census was 111 and required 11.1 physician hours; however, there were only 9 physician hours documented.
During the week of May 20, 2025 through May 26, 2025, the patient census was 112 and required 11.2 physician hours; however, there were only 9 physician hours documented.
During the week of July 1, 2025 through July 7, 2025, the patient census was 116 and required 11.6 physician hours; however, there were only 9 physician hours documented.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Soar is making a concerted effort to expand its medical staff by hiring an additional Medical Doctor (MD). This will allow the organization to extend patient service hours and ensure continuous coverage during existing MDs' vacations. The CEO of Soar will lead the recruitment and hiring efforts, with the immediate goal of securing a candidate within 90 days. This process will be ongoing to meet future needs. The CEO will also be responsible for monitoring the MD-to-patient census ratio to ensure it remains in compliance with all relevant standards |
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.
|
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 three of three applicable patient records reviewed.
Patient # 1 was transferred in and admitted on July 3, 2025 and was still active at the time of inspection. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient # 2 was transferred in and admitted on February 20, 2025 and was still active at the time of inspection. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient # 4 was transferred in and admitted on February 25, 2025 and was discharged on July 8, 2025. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The regional Director shall work with our EMR vendor to develop a new electronic system for all transfer-in documentation. The system will be developed by September 15, 2025. This system will now electronically record and include the initial dosing information, last dose information, admission date, and dosing records for all transfer-in patients. When a patient makes a transfer-in request, the intake counselor must send an email notification to the program director within 24 hours of the request. The intake counselor is responsible for completing all transfer-in documents in the EMR system and sending the required documents to the outside provider within 24 hours of the patient's admission date. To ensure complete documentation, the program director will audit the patient chart upon receiving a transfer-in notification. Any missing or incomplete documentation will be addressed by the program director for correction. An instruction memo detailing this new process will be issued via email from the regional director by September 15th, 2025, when the new system officially goes into use. |
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to document the results of all annual physical examinations given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician, in one of four applicable patient records reviewed.
Patient # 5 was admitted on December 15, 2020 and was discharged on April 18, 2025. The most recent annual physical examination was completed on December 17, 2023 and the next annual physical was due to be completed by December 17, 2024; however, there was no annual physical examination documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
As of August 28, 2025, a new, ongoing procedure is in place to manage annual physical reviews. The Nursing Manager will use the EMR system's self-audit tools, specifically Report #150d (Annual Physical Dues in a Date Range), to identify any overdue or upcoming physical exams. The Nursing Manager will run this report every two weeks and share the results with the Program Director and the administrative assistant, who will then schedule the patient appointments. At the end of each month, the Nursing Manager or a designee will audit the results to confirm completion. Any missing or incomplete documents identified will be addressed by the Program Director. Staff members will have one week to complete all necessary corrections. The process will be ongoing, starting 9/15/2025 and monitored for compliance 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.
|
Observations
Based on a review of patient records, the facility failed to ensure the completion of an annual evaluation of the patient's status by the patient's counselor and was to be reviewed, dated, and signed by the medical director in two of four applicable patient records reviewed.
Patient # 5 was admitted on December 15, 2020 and was discharged on April 18, 2025. The most recent annual evaluation of the patient's status was completed on January 5, 2024 and the next evaluation was due to be completed by January 5, 2025; however, there was no evaluation documented in the record at the time of the inspection.
Patient # 6 was admitted on January 24, 2023 and was discharged on February 21, 2025. The most recent annual evaluation of the patient's status was completed on January 24, 2024 and the next evaluation was due to be completed by January 24, 2025; however, there was no evaluation documented in the record at the time of the inspection.
This is a repeat citation from the November 7, 2022, September 23, 2023, and August 21, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective August 28, 2025 a email that outlines the new procedure for tracking and managing clinical annual reviews has been issued to the clinical staff have from the Regional Director. To ensure all reviews are completed, primary counselors are now required to use Self-Audit Report 150D weekly to identify reviews that need to be addressed. Program Directors and clinical supervisors are directed to run Report #151e (Annual Review/Assessments by Caseload) within the EMR system every two weeks. This report will help identify any overdue or incomplete annual reviews. Any missing or incomplete documentation identified will be addressed by the Program Director, and staff will have one week to complete all necessary corrections. This two-step verification process will begin on September 15, 2025, and compliance will be continuously monitored by the Program Director. |
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.
|
Observations
Based on a review of client records, the facility failed to assure counseling services were being provided according to the individual treatment and rehabilitation plan in four of seven client records reviewed.
Client # 2 was admitted on February 20, 2025 and was still active at the time of inspection. The individual treatment and rehabilitation plan dated March 19, 2025, and the treatment plan update dated on May 28, 2025, indicated the client was to receive one group therapy session per month. The record of service and progress notes indicated the client did not receive any group sessions during the reviewed period.
Client # 3 was admitted on January 19, 2021 and was still active at the time of inspection. The individual treatment and rehabilitation plan updates dated November 29, 2024, January 28, 2025, and March 26, 2025, indicated the client was to receive one group therapy session per week. The record of service and progress notes indicated the client did not receive any group sessions during the reviewed period.
Client # 4 was admitted on February 25, 2025 and was discharged on July 8, 2025. The individual treatment and rehabilitation plan updates dated April 9, 2025, May 7, 2025, and June 26, 2025, indicated the client was to receive one group therapy session per month. The record of service and progress notes indicated that the client received a total of one group session during the reviewed period.
Client # 6 was admitted on January 24, 2023 and was discharged on February 21, 2025. The individual treatment and rehabilitation plan updates dated November 19, 2024 and January 20, 2025, indicated the client was to receive one group therapy session per week. The record of service and progress notes indicated that the client did not receive any group sessions during the reviewed period.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
An instructional memo shall be issued by the regional director by 9/15/2025 to the clinical staff regarding patient treatment attendance. The memo will state that the staff is responsible for ensuring that patients attend their mutually agreement upon treatment requirements as indicated on the treatment plans. The memo will state that the program director needs to run the "patients not counseled report" weekly to identify patients who have not completed treatment based on their agreement. The program director will place patients who have not attended their agreed upon session on hold to meet with their counselor. Patients who still fail to attend sessions will have a non-billable not placed in the chart to indicate an attempt was made but patient refused services. The process of placing patients on hold to attend a counseling session and documenting failures to attend will be ongoing by the primary counselor of the patient. This plan will be in effect by 9/15/2025 and the program director will monitor to ensure poc is followed. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to complete an annual evaluation of the patient's status, which is to be reviewed, dated, and signed by the medical director, was submitted and approved by the Department for the November 7, 2022, September 22, 2023, and August 21, 2024 annual licensing inspections. Failing to complete an annual evaluation of the patient's status, which is to be reviewed, dated, and signed by the medical director was again found to be a deficiency in the August 11, 2025 through August 12, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Within the next 90 days (by 11/28/2025), the CEO will interview and hire a Corporate Compliance Officer. This new officer will be responsible for overseeing our quality assurance and audit review processes, as well as ensuring the completion of all required plans of correction from state and funding sources. The Corporate Compliance Officer will provide a monthly report to both the CEO and the Regional Project Director, who will monitor these processes to ensure timely completion. |