INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on June 18, 2012 through June 20, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corp. Philadelphia 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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705.26 (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 observation, the intake office included a heater that was not permanently mounted or installed.The findings include:On June 19, 2012, at approximately 1 p.m. the intake staff member office on the administrative side of the facility was observed to have a heater that was not permanently mounted or installed. The Human Resource Director confirmed the presence of the heater. This finding was not disputed.
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Plan of Correction
An E-mail went out to all employees that no heaters are permitted in any office or room at Soar, even if it is only used for the fan. All such combination heater/fan must be removed from the building immediately. At the July 10 and 17 staff meeting an announcement will be made of this decision. Our safety officer will inspect all room in Soar quarterly to see the staff are in compliant with this rule. HR Director will check the safety log to see that the quarterly checks are being done. |
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 June 18, 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 # 14, 15, and 16.Employee # 14, 15 and 16 are contracted security guards. The new contract began in April 2012. Fire extinguisher training was due upon staff employment. The facility had not documented fire extinguisher training as of the date of the review.The findings were reviewed with the Facility Director. This is a repeat citation from the January 26, 2012 licensing inspection.
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Plan of Correction
Fire Extinguisher training will be done the first day a new employee comes to Soar including contracted security guards. The HR director or Executive Director will complete this training on day one. This will be in effect as of July 2, 2012. The Regional Project Director will check the records quarterly. The new or any other new security guard company will be aware of the required training the guards must have and agree if they want a contract with Soar. Soar can only be responsible for the Security Guard the first day any new guard from the company comes to work at Soar as they can be changed whenever the guard companies deems it necessary. |
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 staff training of assigned tasks during emergencies upon staff employment.The findings include:Sixteen personnel records were reviewed on June 18, 2012, to verify that staff training of assigned tasks during emergencies occurred upon staff employment. The facility failed to document the completion of staff training of assigned tasks during emergencies in personnel records # 14, 15, and 16.Employees # 14, 15 and 16 are contracted security guards. The new contract began in April 2012. Staff training of assigned tasks during emergencies was due upon staff employment. The facility had not documented staff training of assigned tasks during emergencies as of the date of the review.The findings were reviewed with the Facility Director. This is a repeat citation from the January 26, 2012 licensing inspection.
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Plan of Correction
The new Security guard company was notified that any guards working at Soar must have the mandatory Fire Extinguisher and Emergency training prior to, or on, the first day working at Soar. Any new guard sent to Soar at the last minute for any reason must have at least the fire extinguisher and emergency evacuation trainings prior to, or on, the first day of working at Soar. The HR Director or Executive Director will provide the training. The HR Director will have a log of the trainings. It will be checked quarterly by the Regional Project Director to insure that these training are instituted. |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
Based on a review of the annual report, the facility failed to complete an annual report for the fiscal year of January 1, 2011 to December 31, 2011, that included all of the components.The findings included:The annual report for the fiscal year January 1, 2011, to December 31, 2011, was requested for review. The annual report is to include a statement disclosing names of officers, directors and principal shareholders. The report was bound and only included the name of the Project Director.During a dialogue with the Project Director on June 18, 2012, the Project Director acknowledged that an annual report had not included a statement disclosing names of officers, directors and principal shareholders of fiscal year 2011. The findings were not disputed.
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Plan of Correction
The annual report for the fiscal year January 1, 2011, to December 31, 2011, neglected to include a statement disclosing names of officers, directors and principal shareholders. The report format is now on the computer with a list of the components required. The HR Director will oversee that the Annual report is done in a timely manner and the Executive Director will double check the format for all the componets to ensure all required areas are completed prior to printing. All the reports that were printed have been corrected. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based upon a physical plant tour of the facility, the facility failed to have the fee schedule posted in a prominent place. The findings include:A physical plant tour was conducted on June 19, 2012 at approximately 1:30 p.m. with the clinical director. The fee schedule was posted within the receptionist office behind a wall. It was confirmed by the receptionist that no patients are permitted in the area. The facility failed to have the fee schedule posted in a prominent place. The clinical director confirmed that the fees were not posted.
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Plan of Correction
A copy of the fee schedule is printed and laminated, and hung up by the receptionist window and the intake window in full view for the patients. The lead Clinical Supervisor will be responsible to oversee that the fee schedule remains in full view of the patients, as well as hung up in the Office Managers office no later than July 2, 2012. |
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 two of eleven patient records reviewed. The facility exceeded 4 Pa. Code, Subsection 255.5(b) in five of eleven records reviewed. The findings included:Eighteen patient records were reviewed June 19, 2012 through June 20, 2012. Eleven 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 three patient records reviewed, # 1, 5, 8, 9 and 17.A review of patient record # 1 revealed two handwritten letters written to a judge and a probation officer without a documented date. A consent to release was not documented for information to be disclosed to these individuals. The facility exceeded 4 Pa. Code, Subsection 255.5(b) by releasing information to the judge that included type and frequency of treatment and type of medication. A review of patient record # 5 revealed the counselor contacted another provider on April 14, 2012, without a consent to release information to the provider.A review of patient record # 8 revealed a Pennsylvania Client Placement Criteria form written on 4/27/2012 that included the medication the client was prescribed. This information exceeded 4 Pa. Code, Subsection 255.5(b). A review of patient record # 9 revealed a Pennsylvania Client Placement Criteria form was written on 4/18/2012 that included the medication the client was prescribed. This information exceeded 4 Pa. Code, Subsection 255.5(b).A review of patient record # 17 revealed a consent to release information to Children and Youth that included urine results and dose verification. This information exceeded what is permitted by 4 Pa. Code, Subsection 255.5(b).
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Plan of Correction
A clinical staff training on what is permitted by 4 Pa. Code, Subsection 255.5(b)will be presented to clinical staff no later than July 20, 2012 that will include a copy of 255.5 (b).
The training on Pennsylvania Client Placement Criteria form will provide information on why listing patient medication prescribed is not to be listed on a PCPC and that type of information will exceeded Pa. Code, Subsection 255.5(b). A copy of the code will be given to all clinical staff. The Clinical Directror/Clinical Supervisors will be responsible to check in regular chart reviews that this citation was corrected.
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709.28(e)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(e) Where consent is not required, the project personnel shall:
(2) Inform the client, as readily as possible, that the information was disclosed, for what purposes and to whom.
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Observations
Based on the review of patient records, the facility failed to inform a patient that information was disclosed, for what purpose and to whom in one of one record, # 4.The findings included:Eighteen patient records were reviewed June 19, 2012 through June 20, 2012. A review of patient record # 4 revealed medication information was released to a hospital without a consent to release on March 5, 2012. No documentation was provided within the record indicating the patient was notified of the disclosure of the information, the purpose and who received the information.The findings were reviewed with the clinical director and not disputed.
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Plan of Correction
In the event of information being released to a hospital for emergency purposes without the patients consent. A patient must be notified that the information was released. Soar will create a form just for hospital medical emergencies listing the various reasons. The patient will get a copy of the information being released; the patient will sign this release of information form that they received a copy. This form will be created and a training on the process will be instituted before July 20, 2012. An e-mail will be sent on July 2, 2012 announcing this procedure. The clinical Director/clinical Supervisors will be responsible to see this process in followed. It will be checked by the clinical supervisors during chart audits. |
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 the patient records, the facility failed to provide a personal history that included detail in the areas of family history, legal history, employment/vocational history, educational history, recreational history, prior treatment, client's perception of drug use, family drug abuse history, and sexual history in eleven of eleven records.The findings include: Eighteen records were reviewed on June 19, 2012 and June 20, 2012. Eleven records were reviewed for compliance with the regulations pertaining to personal histories. Specifically, patient records # 1, 3, 5, 6, 7, 8, 9, 10, 16, 17, and 18 failed to include components of the personal history.Record # 1 - Patient was admitted on 4-2-2012 and discharged on 6-8-2012. The personal history was not documented in the record.Record # 3 - Patient was admitted on 4-25-2012 and discharged on 5-7-2012. The facility failed to document a personal history to include detail in the areas of family history, employment/vocation history and sexual history. The recreational history was not documented in the record as of the date of the review.Record # 5 - Patient was admitted on 4-10-2012. The facility failed to document a personal history to include detail in the area of employment/vocation history. The recreational history was not documented in the record as of the date of the review.Record # 6 - Patient was admitted on 5-7-2012. The facility failed to document a personal history to include detail in the areas of legal history and employment/vocational history. The client's perception was not documented in the record as of the date of the review.Record # 7 - Patient was admitted on 4-2-2012. The facility failed to document a personal history to include detail in the area of employment/vocational history.Record # 8 - Patient was admitted on 4-27-2012. The facility failed to document a personal history to include detail in the areas of employment/vocational history and sexual history. The family history, legal history, and recreational history were not documented in the record as of the date of the review.Record # 9 - Patient was admitted on 4-18-2012. The facility failed to document a personal history to include detail in the area of employment/vocational history.Record # 10 - Patient was admitted on 5-25-2012. The facility failed to document a personal history to include detail in the areas of legal history and employment/vocational history.Record # 16 - Patient was admitted on 4-2-2012. The facility failed to document a personal history to include detail in the areas of length and patterns of substance abuse, and sexual history. The legal history was not documented in the record as of the date of the review. The history was dated 6-13-2012. The history is due within 30 days of admission.Record # 17 - Patient was admitted on 4-10-2012. The facility failed to document a personal history to include detail in the area of educational history.Record # 18 - Patient was admitted on 4-5-2012. The facility failed to document a personal history to include detail in the areas of length and patterns of substance abuse, prior treatment history, family history, employment/vocational history and sexual history. The legal history and educational history were not documented in the record as of the date of the review.The findings were reviewed with the clinical supervisor and not disputed. This is a repeat citation from the January 26, 2012 licensing inspection.
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Plan of Correction
We have a new intake form and biopsychosocial that contains all the information required in the areas noted. We will add a few spaces in the job area and do a training for the intake coordinator on the intake portion. We will designate a person to do the biopsychosocials until we have all the new, as well as old counselors trained in how to fill out the information and pull out more than what is just being offered from the patient. The training will be conducted before July 27 for all clinical staff. The Clinical Director/Clinical Supervisors will be responsible to see that these areas are completed according to the regulations during the chart audits.
The Executive Director will pull a few charts audited by the supervisory team to check for compliance. |
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 four of four patient records. Additionally, six of six records failed to provide a psychosocial evaluation to include client problems/ needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude towards treatment and counselors conclusions/ impression. The findings include:Eighteen patient records were reviewed on June 19 through June 20, 2012. Ten of the patient records were required to have a psychosocial evaluation. Per the facility policy, psychosocial assessments will be documented within 30 days of admission. The facility failed to document a psychosocial evaluation in patient records # 1, 8, 16, and 18. Additionally, patient records # 5, 6, 7, 9, 10, and 17 failed to include a psychosocial evaluation that included client problems/ needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude towards treatment and counselors conclusions/ impressions. Patient # 1 was admitted on 4/2/2012 and discharged on 6/8/2012. The psychosocial evaluation was due by 5/2/2012 and was not completed. The facility failed to document the completion of a psychosocial evaluation.Patient # 5 was admitted on 4/10/2012. The psychosocial evaluation was documented on 5/9/2012. The psychosocial evaluation failed to included an evaluation of the client's problems/ needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude towards treatment and counselors conclusions/ impressions.Patient # 6 was admitted on 5/7/2012. The psychosocial evaluation was documented on 5/14/2012. The psychosocial evaluation failed to included an evaluation of the client's problems/needs, assets/strengths, negative factors, attitude towards treatment and counselors conclusions/impressions.Patient # 7 was admitted on 4/2/2012. The psychosocial evaluation was documented on 4/12/2012. The psychosocial evaluation failed to document an evaluation of the client's support systems, and attitude towards treatment.Patient # 8 was admitted on 4/27/2012. The psychosocial evaluation was due by 5/27/2012 and was not completed. The facility failed to document the completion of a psychosocial evaluation as of the date of the inspection.Patient # 9 was admitted on 4/18/2012. The psychosocial evaluation was documented on 5/16/2012. The psychosocial evaluation failed to included an evaluation of the client's problems/needs, support systems, coping mechanisms, and negative factors.Patient # 10 was admitted on 5/25/2012. The psychosocial evaluation was documented on 5/30/2012. The psychosocial evaluation failed to document an evaluation of the client's assets/strengths.Patient # 16 was admitted on 4/2/2012. The psychosocial evaluation was due by 5/2/2012 and was not completed. The facility failed to document the completion of a psychosocial evaluation.Patient # 17 was admitted on 4/10/2012. The psychosocial evaluation was documented on 5/8/2012. The psychosocial evaluation failed to document an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude towards treatment and counselors conclusions/impressionsPatient #18 was admitted on 4/5/2012. The psychosocial evaluation was due by 5/5/2012 and was not completed. The facility failed to document the completion of a psychosocial evaluation.This is a repeat citation from the January 26, 2012 licensing inspection.
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Plan of Correction
Looking at the State findings about the intake/biopsychosocial the is a need for training, as well as change in our form in the areas of client problems/ needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude towards treatment and counselors conclusions/ impression. We will have the clincal team look over the bipsychosocial to improve these areas. Soar will have a formal training on these areas by July 27 as well as the biopsychosocial will be redesigned to capture the information in a more efficient way. The Executive Director will have the Bio redesigned by that date the Clinical Director and Clinical Supervisors will be responsible to train all clinical staff on how to get a better picture on pertinent information.Followup checks will be done at chart audits.
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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, the facility failed to document a treatment plan update in one of one patient record. The findings include: Eighteen patient records were reviewed on June 19 through June 20, 2012. One patient record was required to have a treatment plan update. Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in patient record # 2. Patient # 2 was admitted on October 11, 2011 and discharged on April 5, 2012. The last documented treatment plan update in the record was dated January 10, 2012. The next treatment plan update was due on March 10, 2012. The facility failed to document a treatment plan update prior to the patient being discharged from the program. This finding was discussed with the clinical supervisor and was not disputed.
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Plan of Correction
Soar will have a training for all supervisory staff on tracking treatment plans. A program will be designed to list all patients at Soar and when the next treatment plan is due. A special assistant to the Executive Director will maintain that list and e-mail all clinical counselors and their supervisor of the due date a week in advance, as well as keep a copy of the e-mails in ring book as evident that the e-mail was sent. The Clinical Director will be responsible to oversee that the process is being done and notify the Executive Director if it is deficient. This process will be set up by July 27, 2012. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of patient records, the facility failed to document a record of service which included a chronological listing of all services provided to the patient in five of thirteen patient records.The findings include:Eighteen patient records were reviewed on June 19 through June 20, 2012. A record of service including all services provided were reviewed in thirteen client records. The facility did not document a complete record of service in patient records #1, 3, 8, 10, and 18.
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Plan of Correction
The patient record of services including all services provided were missing in a few patient charts. This is available through the Tower computer billing system. It can be run out of the computer on demand. To rectify this deficiency Soar will designate one staff to run the record of services out monthly and give them to the chart room staff to file. It will be the responsibility of the supervisors to oversee the compliance during the chart audits. This will be in effect by July 30, 2012 |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to document an aftercare plan in two of two patient records.The findings include:Eighteen patient records were reviewed on June 19 through June 20, 2012. Per the facility policy, an aftercare plan a will be completed two weeks prior to discharge for patients who voluntarily or involuntarily complete the program. An aftercare plan was required in two patient records reviewed. The facility did not document an aftercare plan in patient records # 2 and 12. Patient # 2 was admitted on 10/11/11 and was discharged on 4/5/2012. The aftercare plan in the patient record was dated 10/11/2011. The facility failed to update the aftercare plan two weeks prior to discharge, per facility policy. Patient # 12 was admitted on 3/8/11 and discharged on 5/16/2012. The facility failed to document an aftercare plan in this patient record. This finding was reviewed with the facility director and clinical supervisor and was not disputed.
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Plan of Correction
Soar will ad to the policy and procudure manual. An Aftercare plan will be scheduled with the patient two weeks prior to a scheduled discharge for normal completion of the program and finalized the day of D/C. Patients who are discharged under involuntary circumstances will have an instruction sheet for transfer to another agency or NA. CA, MA, etc. The Assistant to the Executive Director will be responsible to see that the discharge information is completed. All counselors will send an e-mail to the Assistant to the Executive Director when a patient is to be discharged under normal circumstances two week prior to D/C. The clinical supervisors will be responsible to oversee this process is completed during chart audits. This process will be set up by July 13, 2012 |
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 that included the patient's reason for treatment, services offered, response to treatment and client's status upon discharge in four of nine patient records.The findings include:Eighteen patient records were reviewed on June 19 through June 20, 2012. Nine records were reviewed for discharge summaries. Four of the nine records did not have discharge summaries that included all required components, # 2, 4, 13, and 15.Patient # 2 was admitted on 10/11/2011 and discharged on 4/7/2012. The discharge summary failed to document the patient's response to treatment and the patient's status upon discharge.Patient # 4 was admitted on 1/30/2012 and discharged on 4/12/2012. The discharge summary failed to document the patient's reasons for treatment and the patient's status upon discharge.Patient # 13 was admitted on 4/7/2011 and discharged on 6/4/2012. The discharge summary failed to document the patient's status upon discharge.Patient # 15 was admitted on 6/30/2011 and discharged on 6/13/2012. The discharge summary failed to document the patient's reasons for treatment, services offered, response to treatment and client status upon discharge. This finding was discussed with the facility director and clinical supervisor and was not disputed. This is a repeat citation from the January 26, 2012 licensing inspection.
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Plan of Correction
A Clinical Staff training on the proper procedures for filling out a D/C summary will be scheduled before 7/27/2012 including all the components including but not limited to the patient's response to treatment, all services rendered and the patient present status, as well as where a patient will go if another level of care is needed including but not limited to another Program, date, time and name of person to call for followup upon discharge.
This will be the responsibility of the Assistant to the Executive Director. The supervisors will also be responsible to notify the Executive Director if during chart audits a proper discharge is in a chart. This will be set up by 7/27/12.
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