INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2012 through January 26, 2012, by staff from the Division of Drug and Alcohol 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records and administrative documentation, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in two of two personnel record.The findings include:Personnel records were reviewed on January 25, 2012. Two personnel records were reviewed that required documentation of monthly meetings between the clinical supervisor and their supervisor. The facility failed to document monthly supervision meetings in personnel record # 3 and 4.Employee # 3 was hired on April 26, 2011 and was promoted to the position of clinical supervisor on August 1, 2011. Monthly supervision meetings were required to take place in August, September, October, November, and December 2011. There was documentation of monthly meetings for employee # 3, however, the information recorded failed to include the duties and performance as it related to their position. Employee # 4 was hired at the project on March 15, 2011 and was promoted to the position of clinical supervisor on December 19, 2011. There was no documentation of monthly supervision in this personnel record as of the date of the inspection. An interview with the facility director took place on January 25, 2012, at which time the findings were acknowledged.
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Plan of Correction
As of 2/29/2012 all monthly supervision notes for the clinical supervisors will be placed in a supervisory staff binder after completion by the Executive Director. The supervision note will address the completion of duties required, as well as the performance of the supervisor in maintaining the requirements of all duties assigned.
The Regional Project Director will oversee that the Executive Director completes this task. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on the review of personnel records, the facility failed to document that each counselor met the qualifications for the position in two of ten personnel records reviewed.The findings included:Sixteen personnel records were reviewed on January 26, 2012. Two of ten personnel records reviewed of counselors did not have documentation of qualifications required, # 9 and 11.Employee # 9 was hired on October 3, 2011 as a counselor. The employee had a qualified bachelor's degree, but lacked one year of clinical experience at the time of hire and therefore was not qualified for designation as a counselor.Employee # 11 was hired on November 28, 2011 as a counselor. The employee had a qualified bachelor's degree, but lacked one year of clinical experience at the time of hire and therefore was not qualified for designation as a counselor.The findings were reviewed with the Facility Director and Clinical Supervisor.
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Plan of Correction
As of 1/27/2012 the counselors who did not meet the counselor qualifications were made assistant counselors, a letter of intent is in their staff file and they are assigned a supervisor to oversee their training. The HR director will be responsible for ensuring all staff hired will be qualified for their position. It is the responsibility of the HR director to review all staff qualifications prior to hire to ensure that all staff meet the requirements for their stated position. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that the counselor assistant documented to the facility director that he/she was working toward counselor status in one of one personnel records. The findings include:Sixteen personnel records were reviewed on January 25, 2012. One record reviewed was a counselor assistant. The facility did not document evidence of the counselor assistant working toward counselor status in personnel record # 5.Employee # 5 was hired on October 5, 2011 as a counselor assistant. The calendar year ended on December 31, 2011. The counselor assistant failed to document how they were working toward counselor status. Staff interviews with the facility director and clinical supervisor confirmed this finding.
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Plan of Correction
Counselor Assistant has documented in writing her intent for working toward counselor status and it is included in the staff file. She will document in December what was done working towards her degree. The HR director will be responsible to see this is documented in the staff file. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on the review of the personnel records and the facility's policy and procedures, the facility failed to document an assessment of staff training needs for the January 1, 2012 through December 31, 2012 training year in fifteen of sixteen personnel records reviewed. The findings included: Sixteen personnel records were reviewed on January 25, 2012. According to the facility's policy and procedures, the facility will document each year, at the beginning of December, a needs assessment for each employee during a clinical staff meeting. The facility failed to document a needs assessment in personnel records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, and 16.The findings were reviewed with the Facility Director and Clinical Supervisor and were not disputed.
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Plan of Correction
HR Director prepared an assessment of staff training needs for each employee. As of 2/17/2012 it has been completed. The HR Director will ensure that all new hires complete a form within thirty days of hire to assist in the development or their training plan. The HR director is going to utilize a spreadsheet to ensure that the training needs assessments are completed every year in December according to SOAR's policy and procedure manual. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the facility staffing requirements summary report and personnel records, the facility failed to provide documentation of individual training plans in 30 out of 31 personnel records.The findings include:The facility staffing requirements summary report and personnel records were reviewed on January 25, 2012. Individual training plans were required in 30 personnel records. The facility did not document individual training plans for the January 1 - December 31, 2012 training year in 30 records according to the staffing requirements summary report.An interview with the facility director, clinical supervisor, and human resource director on January 25, 2012 confirmed that the staff training plans for 2012 were not completed.
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Plan of Correction
All but three training plan were done while the inspection team was present and the other completed within 2 days. The HR Director will be responsible to see the training plans are completed. |
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.
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Observations
Based on a review of the staffing requirements facility summary report, the facility failed to provide documentation of HIV/AIDS and TB/STD training for five of five personnel.The findings include:The staffing requirements facility summary report was reviewed January 25, 2012. Five support personnel were required to have documentation of HIV/AIDS and TB/STD training within the first two years of employment. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for personnel records #17, 18, 19, 20, and 21.Employee # 17 is a receptionist and was hired January 21, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by January 21, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the inspection.Employee # 18 is an LPN and was hired November 10, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by November 10, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the inspection.Employee # 19 is a consultant and was hired January 3, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by January 3, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the inspection.Employee # 20 is a contractual guard and was hired September 3, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, by September 3, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the inspection.Employee # 21 is a contractual guard and was hired September 15, 2009. HIV/AIDS and TB/STD training was to be completed within two years of hire, by September 15, 2011. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the inspection
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Plan of Correction
All staff new or old will have had HIV/AIDS and TB/STD trainings by March 1, 2012 if it was not acquired previously. The HR director will create a spread sheet to note when the training is due and when it was done. This will insure all staff will be compliant to the required trainings. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of staff training documentation, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of two personnel records reviewed.The findings included:Sixteen personnel records were reviewed on January 25, 2012. Two personnel records of counselors were required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel records # 14 and 15.Employee # 14 was hired on October 12, 2010. The facility training year is from January through December. The training year for January 2011 to December 2011 was reviewed. Employee # 14 only completed 15 clock hours of annual training in 2011.Employee # 15 was hired on November 14, 2008. The facility training year is from January through December. The training year for January 2011 to December 2011 was reviewed. Employee # 15 only completed 16 clock hours of annual training in 2011.The Facility Director and Clinical Supervisor confirmed this finding on January 25, 2012.
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Plan of Correction
The two counselors that did not have the acquired trainings have been verbally warned and documented in their chart, as well as reminded they are responsible for these trainings. The HR director will establish a training book listing each employee and the hours on a quarterly basis as they are achieved. The supervisors will be responsible to see that the counselors meet their requirements. |
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 review of the physical plant tour, it was determined that the facility failed to maintain the interior and exterior of the building to be free of hazards and in good repair.The findings were:A physical plant inspection conducted on January 26, 2012 revealed that the utility room located on the second floor that housed the furnace and electrical panels contained at least six boxes of plastic cups, holiday decorations, a small can of paint, two large plastic bins, a large cardboard box, and a mop. The storage of these items in the heating system closet reduced the ventilation for the heating system and created a potential fire hazard. Further, the contents stored in the utility room reduced accessibility to the electrical panel. During the physical plant tour of the exterior grounds, cigarette butts were observed in an area of mulch. This would be considered a hazard if the ground were dry as mulch is combustible. There was a cigarette butt container that, by observation, was not always being utilized as cigarette butts were observed on the ground.. The findings were confirmed by the facility director. The items that were observed to be a hazard in the utility room were removed by facility staff during the inspection.
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Plan of Correction
The utility room will be cleaned and free of cardboard boxes. There will be plastic containers with lids housed on one wall of the room for storage. No paint or flammable liquids will be in the room. Any mops or brooms will be hung on the wall in an orderly fashion if they are in the room. Nothing will be in front of the heater, hot water heater or electrical box. The room is large enough for a few plastic containers for storage. The cigarette butts were blown in the area by a person contracted to clean the area. They are no longer with SOAR. The area was cleaned out and signs to keep the area clean were posted. We did let the other tenants in the building know that it was observed that their patients and customers were also littering the area. SOAR has instructed the guards to help keep the patients/PIR from throwing cigarettes in that area and to place them in the containers. The Executive Director will check out these room no less that on a quarterly basis. The supervisors will also report on a monthly basis on the conditions of the rooms. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during the physical plant inspection, the facility failed to provide an unobstructed exit for the secondary rear exit.The findings include:A physical plant inspection was conducted on January 26, 2012. The rear hallway on the second floor had two stacks of wood trim approximately eight feet in length in the hallway, as well as, a stack of five boxes at the top of the stairway posing an obstruction to the emergency exit. On the lower level, there was an exit that had a dead bolt lock and a doorknob lock. During the physical plant tour this door was found locked. This exit is obstructed and not operable at all times.The facility director confirmed the door was locked and the items on the floor in the hallway were obstructing the exits.
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Plan of Correction
Our safety team will be observing that area weekly and checking the lighting. The lock with a dead bolt was in another hall location and was changed to a panic bar last week. The dead bolt was removed from the door. The emergency lighting system is intact. SOAR will have our safety committee check the lights in the area weekly and record the findings, as well as note when the bulb(s) were changed. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on observation during a physical plant inspection, the facility failed to light interior exits and stairs at all times.The findings include:On January 26, 2012, a physical plant inspection was conducted. The light bulb was not lit in the interior hallway leading to a flight of stairs to exit the facility. The facility director confirmed this finding.
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Plan of Correction
The light bulb was changed while that state inspectors we at Soar. The other lights in the same hall were in good operating condition. Our safety team will do weekly checks on the light bulbs in the fire escape hall. The supervisor will oversee this is completed.
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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
Based on observation during the physical plant inspection, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.The findings include: The physical plant inspection took place on January 26, 2012. There were three fire extinguishers on the second floor. All three fire extinguishers were observed to have expired inspection tags. They were inspected in November of 2010 and should have been inspected in November of 2011. The facility director confirmed this finding.
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Plan of Correction
The fire inspection company that services the fire extinguishers came out at SOAR January 26, 2012 to inspect all the fire extinguishers in the building and re-tage. The HR Director will be responsible to have the fire inspection team come out to Soar every December to re-inspect all the extinguishers, or in the event that one had to be used they will be called immediately for replacement or recharging.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document fire extinguisher training upon staff employment.The findings include:Sixteen personnel records were reviewed on January 25, 2012 to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records # 5, 6, 9, and 10.Employee # 5 was hired on 10/5/2011 and fire extinguisher training was due upon hire. The facility documented fire extinguisher training was completed on 10/24/2011, nineteen days following employment. Employee # 6 was hired on August 24, 2011 and fire extinguisher training was due upon hire. The facility documented fire extinguisher training completion on 10/12/201, over a month following employment.Employee # 9 was hired on October 3, 2011 and fire extinguisher training was due upon hire. The facility documented fire extinguisher training completion on 10/28/2011, nine days following employment.Employee # 10 was hired 9/16/2011 and fire extinguisher training was due upon hire. The facility documented fire extinguisher training completion on 10/28/2011, over a month late following employment. The facility director confirmed this finding.
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Plan of Correction
There is a training flyer for all new employees on the way to use a fire extinguisher and staff well have a copy, as well as individual instruction within 7 days of hire and documented in the staff files. All staff will be trained on how to use a fire extinguisher individually, as well as in group training packet. All new hires have been trained and any new hire will be trained in the 7 day window when hired, including guards and consultant that are working on the premises at SOAR. The Executive Director will oversee this is accomplished. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log, the facility failed to document seven monthly fire drills. The findings include: The fire drill log was reviewed on January 25, 2012. The log was to cover January 2011 to December 2011. The log provided documentation from August 2011 to December 2011. The facility failed to document fire drills for the following months in 2011: January, February, March, April, May, June and July. This finding was confirmed by the facility director.
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Plan of Correction
Fire drills will be conducted monthly on different days and at different times as regulations require and logged in the fire drill book. The lead supervisor will oversee this is completed and documented. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed to document that all personnel were trained to perform assigned tasks during emergencies upon staff employment.The findings include:Sixteen personnel records were reviewed on January 25, 2012 to verify that staff had been trained to perform assigned tasks during emergencies upon employment. The facility failed to document the completion of training to perform assigned tasks during emergencies upon staff employment in personnel records # 5, 6, 9, and 10.Employee # 5 was hired on 10/5/2011. Training to perform assigned tasks during emergencies was due upon hire. The facility documented emergency training on 10/24/2011, twelve days following hire. Employee # 6 was hired on August 24, 2011. Training to perform assigned tasks during emergencies was due upon hire. The facility documented emergency training on 10/12/2011, over a month late following hire. Employee # 9 was hired on October 3, 2011. Training to perform assigned tasks during emergencies was due upon hire. The facility documented emergency training on 10/28/2011, 25 days following hire.Employee # 10 was hired 9/16/2011. Training to perform assigned tasks during emergencies was due upon hire. The facility documented emergency training on 10/28/2011, over a month following hire. The facility director confirmed this finding.
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Plan of Correction
It was duly noted that staff were not trained in the prescribed time for fire emergencies and has been corrected. All staff have had training since the State Inspection team was at Soar. The supervisors will be responsible to see the staff is scheduled for this training and the HR Director will keep a record of the trainings. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill log, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.The findings include: The fire drill logs were reviewed on January 25, 2012. The facility's hours of operation are 5:00 a.m. until 3:30 p.m. The facility failed to document a fire drill between the hours of 5:00 a.m. and 11:00 a.m. for the five months of documentation that was provided. This finding was confirmed by the facility director.
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Plan of Correction
The fire drills will be conducted monthly as required. As of February 17, 2012. The lead supervisor will be responsible to run the fire drills. They will be conducted all different times of the work day, as well as on different days a week. A schedule of the drills was generated and posted with the HR director as a back up reminder for the supervisor. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of administrative documentation, the project failed to document the completion of an annual audit of financial activities by the end of the project's fiscal year, as required by regulation.The findings include:A financial audit was provided that included activities of September 2009 to July 2010. The project director was interviewed on January 25, 2012. The project director confirmed that an annual audit of financial activities has not been completed for the full fiscal year of 2010/2011. The project director indicated that they changed their fiscal year to follow the calendar year and had not done an audit that included the months of August 2010 through December 2010.
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Plan of Correction
The Regional Project Director will inform the board of directors at the April 12, 2012 board meeting that the aduit is due by March 31 each calendar year.
This years audit will be completed by 6/30/12 by the Regional Project Director. The audit will be scheduled each year by the Regional Project Director to be completed by March 31.
This years audit 2011 as well as the six months 2010 that were not included in the previous year will be completed by June 30th.
The Regional Project Director will remind the board of directors annually at the January meeting that the audit is due. The Project Manager will monitor for compliance. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in 4 of 6 patient records reviewed. The findings included:Thirteen patient records were reviewed January 26, 2012. Six records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in four of six records reviewed, # 1, 2, 3, and 6. A review of patient record # 1 revealed information was released to a funding source on October 7, 2011. The patient did not sign a release prior to releasing information for the funding entity. A review of patient record # 2 revealed information was released to a funding source on August 24, 2011. The patient did not sign a release prior to releasing information for the funding entity. A review of patient record # 3 revealed information was released to a funding source on November 1, 2011. The patient did not sign a release prior to releasing information for the funding entity. A review of patient record # 6 revealed information was released to a funding source on September 2, 2011. The patient did not sign a release prior to releasing information for the funding entity.
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Plan of Correction
On February 1, 2012 the intake coordinators were informed about the deficency and corrected. By March 9, 2012 the intake coordinators and clinical staff that may assist in the intake process will be re-trained and responsible for insuring that prior to checking EVS a patient release of information will be signed, as well as all releases. The intake coordinators will be supervised by the program director. Spot checks will be done on all release weekly by the director and documented. The clinical supervisor will also check the release are done during chart audits. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of patient records, the facility failed to inform the patient of the facility's reason for involuntarily terminating the patient in 6 of 6 patient records. The findings include:Thirteen patient records were reviewed on January 26, 2012. The facility's decision to involuntarily terminate the patient's treatment was required in six patient records. The facility did not document, in writing, of a decision to involuntarily terminate the patient's treatment at the facility in patient records # 7, 8, 9, 10, 12, and 13.
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Plan of Correction
The clinical supervisors will be responsible for training clinical staff and will oversee the counselors compliance at monthly individual supervision sessions and/or chart audits. An e-mail was sent to all clinical staff on February 26, 2012 with instructions on involuntary termination procedures by the lead supervisor. To insure this issue is rectified quarterly trainings will be scheduled by the HR Director on involuntary termination. Patients will be given a letter notifying them of their right to appeal and the process for the appeal.
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709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of patient records, the facility failed to give the patient an opportunity to request reconsideration of a decision terminating treatment. The findings include:Thirteen patient records were reviewed on January 26, 2012. The facility was required to give the patient an opportunity to request reconsideration of a decision terminating treatment in six patient records. The facility did not document, in writing, an opportunity for the patient to request reconsideration of a decision to involuntarily terminate in patient records # 7, 8, 9, 10, 12, and 13.
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Plan of Correction
Any patient that is to be terminated from treatment will be given a letter within 24 hour of the decision. The clinical supervisors will be responsible to see that staff completed the D/C letter in 24 hours and be placed in the patients chart. A progress not will be generated by the counselor. A e-mail with instructions was sent to all clinical staff on the procedure on February 26, 2012. The D/C letter will provide the pt. with information that they have a right to appeal the decision with the Project or Executive Director. A copy of the D/C will be given to the directors for their log book of all involuntary treatment discharges As of February 26, 2012 forward. The log will be initiated by March 9, 2012 to aid in correcting the deficiency. Clinical Supervisors will be responsible for this procedure. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of patient records, the facility failed to document a drug and alcohol history that included lengths and patterns of use in seven of seven records reviewed.The findings included: Thirteen patient records were reviewed on January 26, 2012. Seven patient records were reviewed for documentation of a drug and alcohol history that included lengths and patterns of use. The facility failed to document in patient records # 1, 2, 3, 4, 5, 6, and 7. Patient records # 1, 2, 3, 4 and 5 failed to document a drug and alcohol history that included lengths and patterns of use.Patient records # 6 and 7 failed to include a drug and alcohol history. This finding was discussed with the facility director and clinical supervisor.
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Plan of Correction
A new intake to bio-psychosocial was designed to show the lengths and patterns of D&A use. Training on the new form will be completed by March 13, 2012. It will be a formal training set up by the HR director. It is the responsibility of the clinical supervisors to see that all clinical staff are trained on the new form. The clinical supervisors during chart audits will check that D&A history has included lengths and patterns of use. It is also the responsibility of the clinical supervisors to see that all new staff are trained on the form within the first 7 days of hire and documented in the staff files. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of patient records, the facility failed to provide a personal history that included detail in the areas of family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history in four of seven records.The findings include: Thirteen records were reviewed for compliance on January 26, 2012. Seven records were reviewed for a personal history that included prior treatment history, client's perception of drug use, family history, legal history, employment/vocational history, education history, military history, recreational history, family drug abuse history, and sexual history. The facility failed to document the required information in patient records # 2, 4, 6 and 7.Patient records # 2, 4, and 6 failed to document a personal history that included family drug abuse history, legal history, employment/vocational history, education history, military history, recreational history, family history, and sexual history. Patient record # 7 failed to document a personal history that included prior treatment history, client's perception of drug use, family history, legal history, employment/vocational history, education history, military history, recreational history, family drug abuse history, and sexual history. These findings were confirmed by the facility director and clinical supervisor.
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Plan of Correction
A new intake and bio-psychosocial form was designed that will include a more comprehensive history of a patient. A formal training will be done by March 13, 2012. The clinical supervisors will be responsible to see that the patient information is completed on the form. Chart audits for the new form will be conducted weekly on all new intakes for the months of March and April 2012.The director will be notified of any bio-psychosocial not being completed. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of patient records, the facility failed to document a psychosocial evaluation in six of seven patient records.The findings include:Thirteen patient records were reviewed on January 26, 2012. Seven of the patient records were required to have a psychosocial evaluation. Per the facility policy, psychosocial evaluations are required to be completed within 30 days of admission. The facility failed to document a psychosocial evaluation in client records # 1, 2, 4, 6 and 7. Patient record # 3 failed to document a psychosocial evaluation that was evaluative and dated. Patient # 1 was admitted on October 7, 2011. The psychosocial evaluation was due by November 7, 2011 and was not completed. The facility failed to document the completion of a psychosocial evaluation as of the date of the inspection.Patient # 2 was admitted on August 24, 2011. The psychosocial evaluation was due by September 24, 2011 and was not completed. The facility failed to document the completion of a psychosocial evaluation as of the date of inspection.Patient # 3 was admitted on November 1, 2011. The psychosocial evaluation was due by December 1, 2011. The facility failed to document a psychosocial evaluation that included the patient's problems/needs, assets/strengths, support systems, and coping mechanisms. The document was not dated. It could not be determined if what was documented was within the required timeframe. Patient # 4 was admitted on August 11, 2011. The psychosocial evaluation was due by September 11, 2011 and was not completed. The facility failed to document the completion of a psychosocial evaluation as of the date of the inspection. Patient # 6 was admitted on September 2, 2011. The psychosocial evaluation was due by October 2, 2011 and was not completed. The facility failed to document the completion of a psychosocial evaluation as of the date of inspection. Patient # 7 was admitted on April 27, 2011. The psychosocial evaluation was due by May 27, 2011 and was not completed. The facility failed to document the completion of a psychosocial evaluation as of the date of the inspection. The facility director and clinical supervisor confirmed the psychosocial evaluations were not completed.
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Plan of Correction
By March 13, 2012 Soar will provide training on the new bio-psychosocial. In the next 2 staff meeting in March staff will be reminded that all Psychosocial must be done in 30 days. A copy of the new form will be provided to all clinical staff with brief instruction on its use prior to the training to be scheduled by the HR director. The Supervisors will be responsible to check that the Bio-psychosocial is completed during chart audits and spot checks. The clinical supervisors will be responsible for their staff to complete this task in the required time frame.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of patient records the facility failed to document an individual treatment and rehabilitation plan in four of seven patient records reviewed.The findings include:Thirteen patient records were reviewed on January 26, 2012. Seven patient records were reviewed for treatment and rehabilitation plans. According to the facility's policy and procedures, a treatment and rehabilitation plan will be completed within thirty days of admission. Treatment and rehabilitation plans need to include measurable short and long term goals and shall be developed with the client. The facility failed to document treatment and rehabilitative plans in four of seven patient records. The facility failed to document a treatment and rehabilitation plan in patient records # 1 and 5 that had measurable goals. The goals were incongruent and did not properly identify a short term goal versus a long term goal. Patient # 2 was admitted on August 24, 2011. The facility completed a treatment and rehabilitation plan on September 17, 2011. The facility failed to document a complete personal history and a psychosocial evaluation, therefore the basis of the treatment and rehabilitation plan did not include patient's input.Patient # 4 was admitted August 11, 2011. The facility failed to document an individual treatment and rehabilitation plan. The treatment and rehabilitation plan was due by September 11, 2011. The facility failed to document a treatment and rehabilitation plan for this patient as of the date of the inspection. The findings were confirmed by the facility director and clinical supervisor.
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Plan of Correction
On February 14, 2012 Soar staff received information on treatment plans a formal training will be scheduled by April 15 by the HR Director and clinical staff will be trained on treatment plans. The clinical supervisors will be responsible for the staff to complete treatment plans. During supervision and chart audits supervisors will oversee the process.
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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 patient records it was determined that the facility failed to document the patient's progress as it related to the goals identified in the treatment and rehabilitation plan in three of five patient records reviewed.The findings were:Thirteen patient records were reviewed on January 26, 2012. Five patient records were reviewed for treatment plan updates that included progress as it related to the goals identified in the treatment and rehabilitation plan. Per the facility's policy and procedures, treatment plan updates are required every sixty days. The facility failed to document in the treatment plan update the patient's progress as it related to the the goals identified in the individualized treatment and rehabilitation plan in patient records # 1 and 2. New goals were identified in the treatment plan update without documenting the progress of previous goals identified. The facility failed to document a treatment and rehabilitation plan update in patient record # 4.Patient # 1 was admitted on October 7, 2011. The comprehensive treatment and rehabilitation plan was documented on November 5, 2011. The treatment and rehabilitation plan update was completed on January 5, 2012. The facility failed to include progress as it related to the current goals on the comprehensive treatment and rehabilitation plan. The facility documented two new goals without documenting the progress on the previous goals. Patient # 2 was admitted on August 24, 2011. The comprehensive treatment and rehabilitation plan was documented on September 17, 2011. The treatment and rehabilitation plan update was due on November 17, 2011. The treatment and rehabilitation plan was documented on December 18, 2011, one month late. The next treatment and rehabilitation plan was documented on January 14, 2012. The treatment plan update showed that an individual objective was removed without addressing progress made towards that goal. Patient # 4 was admitted on August 11, 2011. A comprehensive treatment and rehabilitation plan was due on September 11, 2011. A treatment and rehabilitation plan update would have been due on November 11, 2011 and January 11, 2011. The facility failed to document treatment and rehabilitation plan updates for this patient as of the date of the inspection.
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Plan of Correction
Instructions on the new revised treatment plan and how to use it will be issued on March 15, 2012. The clinical supervisors will be responsible for the oversight of clinical staff completeing treatment plans on time. Monthly chart audits by the supervisors will be a way to oversee the deficiency is corrected. A excel spread sheet will assist in the process. The spread sheet will be done by March 31, 2012. |
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
Based on a review of patient records, the facility failed to assure patients received counseling services according to their individual treatment plans in three of three patient records.The findings include:Thirteen patient records were reviewed on January 26, 2012. Three records were reviewed for counseling services provided according to the treatment plan. Three of three patient records did not have counseling services provided as identified in their treatment plans, specifically records # 2, 3, and 7.Patient # 2 was admitted on 8/24/2011. According to the comprehensive treatment and rehabilitation plan completed on September 17, 2011, the patient was to receive biweekly individual sessions and five group sessions per week. There were no documented individual sessions in September 2011. The patient attended four groups in September. In October 2011, the patient received two individual sessions and one group session. In November 2011, the patient received one individual session and no group sessions. In December 2011, the patient received one individual session and four group sessions.Patient # 3 was admitted on 11/1/2011. According to the comprehensive treatment and rehabilitation plan in December 1, 2011, the patient was to receive one individual session and four group sessions per week. In November 2011, the patient received one individual session. In December 2011, the patient received two individual sessions and no group sessions. In January 2012, the patient received two individual sessions and no group sessions.Patient # 7 was admitted on 4/27/2011 and discharged on 9/25/2011. According to the comprehensive treatment and rehabilitation plan in April 27, 2011, the patient was to receive one individual session and five group sessions per week. In May 2011, the patient received three individual sessions and 19 group sessions. In June 2011, the patient received three individual sessions and 11 groups. In July 2011, the patient received two individual sessions and four groups. In August 2011, the patient received no individual sessions and one group. In September 2011, the patient received three individual sessions and no group sessions.The findings were reviewed with the project director, facility director and clinical supervisor and were not disputed.
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Plan of Correction
The clinical team will receive a weekly list of the groups the patient attended. This list will be prepared by the supervisors Starting March 30, 2012. All counselors will be responsible to work with the patient to improve treatment complience for groups. The counselors will be responsible to note why a patient does not attend the required group sessions, as well as work out a plan of correction for patients who refuse to go to groups. Chart audits will reflect compliance. It is the responsibility of the supervisors to see this group attendance list is completed and distributed to the counselors. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of patient records, the facility failed to ensure patients received counseling services on a regular and scheduled basis in seven of thirteen patient records reviewed.The findings include:Thirteen patient records were reviewed on January 26, 2012. All records were reviewed for the provision of counseling services on a regular basis. Seven out of thirteen patient records did not have counseling services provided on a regular basis, specifically records # 2, 7, 8, 9, 10, 12 and 13.Patient # 2 was admitted on 8/24/2011. The last individual counseling session documented was 12/18/2011 as of the date of the site visit.Patient # 7 was admitted on 4/27/2011 and discharged on 9/25/2011. The last individual counseling session documented was 7/11/2011.Patient # 8 was admitted on 12/4/2008 and discharged on 10/6/2011. The last individual counseling session documented was 7/18/2011.Patient # 9 was admitted on 3/22/2011 and discharged on 7/6/2011. The last individual counseling session documented was 5/16/2011.Patient # 10 was admitted on 4/6/2011 and discharged on 8/5/2011. The last individual counseling session documented was 6/29/2011.Patient # 12 was admitted on 4/30/2008 and discharged on 8/8/2011. The last individual counseling session documented was 7/14/2011.Patient # 13 was admitted on 4/30/2008 and discharged on 8/8/2011. The last individual counseling session documented was 12/30/2010.The findings were reviewed with the project director, facility director and clinical supervisor and were not disputed.
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Plan of Correction
A weekly report run on the Tower computer system will provide each counselor with a list of patients group attendance. The counselor will be responsible to improve the patient compliance with groups and individual sessions or give and explanation of why the patient is not complient in the progress notes and/or treatment/recovery plans. At individual supervision sessions with the clinical supervisor this attendance issue in individual and group sessions will be addressed. A spread sheet of counselors case load compliance will be generated in a spreat sheet by March 31, 2012 |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of the facility's policy and procedures and patient records, the facility failed to document completion of case consultations in three of five patient records.The findings include:Thirteen patient records were reviewed on January 26, 2012. Five records were reviewed for case consultations. Per facility policy, case consultations are to be completed at least every 90 days. Three of five records did not contain documentation of case consultations completed every 90 days, specifically records # 4, 6 and 7.Patient # 4 was admitted on 8/11/2011. No case consultations were documented in the patient record. Patient # 6 was admitted on 9/2/2011. No case consultations were documented in the patient record.Patient # 7 was admitted on 4/27/2011. No case consultations were documented in the patient record.The findings were reviewed with the project director, facility director and clinical supervisor and were not disputed.
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Plan of Correction
A training on case consultations will be held March 20,2012. The supervisors will discuss when and how case consultations are to be completed within 90 days per SOAR policy. The clinical supervisors will oversee this task is completed. Chart Reviews will reflect compliance. A Excel spread sheet will be prepared to keep track of the time and assist in correcting the deficiency. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document a complete discharge summary in six of seven patient records.The findings include:Thirteen patient records were reviewed on January 26, 2012. Seven records were reviewed for discharge summaries. Six of seven records did not have discharge summaries that included all required components, # 7, 8, 9, 10, 12, and 13.Patient # 7 was admitted on 4/27/2011 and discharged on 9/25/2011. The discharge summary failed to document the services offered to the patient and the patient's status upon discharge.Patient # 8 was admitted on 12/4/2008 and discharged on 10/6/2011. The discharge summary failed to document the patient's reasons for treatment, patient's response to treatment and the patient's status upon discharge.Patient # 9 was admitted on 3/22/2011 and discharged on 7/6/2011. The discharge summary failed to document the services offered to the patient, the patient's response to treatment, and the patient's status upon discharge.Patient # 10 was admitted on 4/6/2011 and discharged on 8/5/2011. The discharge summary failed to document the services offered to the patient, the patient's response to treatment, and the patient's status upon discharge.Patient # 12 was admitted on 4/30/2008 and discharged on 8/8/2011. The discharge summary failed to document the services offered to the patient and the patient's status upon discharge.Patient # 13 was admitted on 4/30/2008 and discharged on 8/8/2011. The discharge summary failed to document the patient's reasons for treatment, the patient's response to treatment, and the patient's status upon discharge.The findings were presented to the project director, facility director and clinical supervisor and were not disputed.This is a repeat citation from the December 28, 2010 licensing inspection
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Plan of Correction
The supervisors will be accountable to see that proper discharge summaries are completed. There will be training on D/C summaries on March 23,2012 on the proper procedures in completing our new D/C summary. Chart audits will identify any deficiency by a counselor. An E-mail instruction sheet will be sent out to the counselors by March 9, 2012 on how to complete the summary. The clinical supervisors will count on chart audits, as well as a log sheet for each counselor to fill out on all D/C weekly. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of the facility's policies and patient records, the facility failed to document follow up information in six of seven patient records.The findings include:Thirteen patient records were reviewed on January 26, 2012. Seven records were reviewed for documentation of follow up information. Per facility policy, follow up is to occur within 30 days after discharge. Six of seven records did not have follow up information documented, # 7, 8, 9, 10, 12, and 13.Patient # 7 was admitted on 4/27/2011 and discharged on 9/25/2011. Follow up documentation was due by October 25, 2011. No follow up was documented at the time of the site visit.Patient # 8 was admitted on 12/4/2008 and discharged on 10/6/2011. Follow up documentation was due by November 6, 2011. No follow up was documented at the time of the site visit.Patient # 9 was admitted on 3/22/2011 and discharged on 7/6/2011. Follow up documentation was due by August 6, 2011. No follow up was documented at the time of the site visit.Patient # 10 was admitted on 4/6/2011 and discharged on 8/5/2011. Follow up documentation was due by September 5, 2011. No follow up was documented at the time of the site visit.Patient # 12 was admitted on 4/30/2008 and discharged on 8/8/2011. Follow up documentation was due by September 8, 2011. No follow up was documented at the time of the site visit.Patient # 13 was admitted on 4/30/2008 and discharged on 8/8/2011. Follow up documentation was due by September 8, 2011. No follow up was documented at the time of the site visit.The findings were presented to the project director, facility director and clinical supervisor and were not disputed.This is a repeat citation from the December 28, 2010 licensing inspection.
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Plan of Correction
Follow up with patient within 30 days after discharge is a Soar policy. We have assigned an intake coordinator to As of February 21, 2012 follow-ups for D/C patients will be done on a weekly census sheet run from the Tower system on any D/C for that week. A phone call and/or letter will be generated according to the release form in the patients chart. It is the responsibility of the Intake Coordinator to do the follow up but the responsibility of the clinical supervisors to see that the patient is D/C in the Tower System so the weekly check done by the Intake Coordinator are accurate. Any missing follow ups for the last 6 months will be followed up. Every patient was followed up by March 5, 2012. The Intake coordinator and the lead supervisor will discuss this monthly to assure complience. A Excel spread sheet will be generated by 3/30/12 to assure compliance.
Counselors will follow-up on patients referred out within seven days of D/C by calling and or faxing to the receiving agency to assure the patient is in treatment.
The supervisors will be responsible to assure compliance during chart audits and a spread sheet will be used to assure compliance monitored by the supervisors.
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