INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2012 through February 1, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corporation Chester, 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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704.7(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 one of four personnel records reviewed.
The findings included:
Ten personnel records were reviewed on January 31, 2012. Four of the ten personnel records were reviewed for counselor qualifications. Employee # 7 did not meet the qualifications for counselor.
Employee # 7 was hired on March 7, 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 was not qualified for designation as a counselor.
The findings were reviewed with the Facility Director and not disputed.
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Plan of Correction
Program Director has met with both staff persons and completed Status Changes to Counselor Assistant. Program Director will provide close supervision to staff #6 who is a full time employee and has a Bachelor's Degree. Staff member #7 currently works 2 hrs weekly and has a Bachelor's Degree. Program Director will also monitor with close supervision. Program Director will monitor for compliance in meeting criteria for full counselor through direct supervision and quarterly reports from HR Director. All new hires will have credentials thoroughly reviewed by Program Director and/or HR Director prior to job offer |
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 the review of personnel records, the facility failed to document HIV/AIDS and TB/STD training in two of two personnel records.
The findings include:
Ten personnel records were reviewed on January 31, 2012. Two personnel records were reviewed for documentation of HIV/AIDS and TB/STD training. The facility failed to document HIV/AIDS and TB/STD training in personnel records # 9 and 10.
Employee # 9 is a support staff member and was hired on December 6, 2008 as the Office Manager. A Department approved curriculum in HIV/AIDS and TB/STD training was due to be completed no later than December 6, 2010. Documentation of this training was not available at the time of the review.
Employee # 10 is a support staff member and was hired on June 20, 2008 as the Intake Coordinator. A Department approved curriculum in HIV/AIDS and TB/STD training was due to be completed no later than June 20, 2010. Documentation of this training was not available at the time of the review.
The project director confirmed this finding.
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Plan of Correction
Four of the staff at the Chester clinic have already had the mandatory TB/STD training. All other staff at the site are scheduled to attend the training. Program director will monitor for staff compliance through training compliance reports from HR Director. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on documentation filed in personnel records, the facility failed to ensure that at least one-half of all training was provided by trainers not directly employed by the project in two of three personnel records.
The findings include:
Ten personnel records were reviewed on January 31, 2012. Three personnel records were reviewed for required training hours. Two of three employees failed to document that at least one-half of their training hours were provided by trainers not directly employed by the project, specifically personnel records # 3 and 4.
Employee # 3 was required to have 12 hours of training for the 2011 training year and facility documentation indicated the employee received 14.5 hours of training. A review of the employee's training record revealed that only 2.5 hours of the 14.5 hours of training were provided by a trainer not directly employed by the project.
Employee # 4 was required to have 25 hours of training for the 2011 training year. A review of the employee's training record revealed that the employee had obtained only 13 hours of the required 25 hours with only 3 hours of the training provided by a trainer not directly employed by the project.
This finding was discussed with the project director and was not disputed.
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Plan of Correction
Program Director will address training requirement as cited in 704.11 (3) &(4). All applicable staff will obtain 50% of their training through an external source. Program Director will monitor for compliance through staff supervision and quarterly reports from HR Director. |
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 maintained in the personnel record, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records reviewed.
The findings included:
Ten personnel records were reviewed on January 31, 2012. Four personnel records were counselors and four were required to complete 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel records # 4.
Employee # 4 was hired on November 23, 2008. The facility training year is from January through December. The training year for January 2011 to December 2011 was reviewed and, according to the documentation provided, employee # 4 completed 13 clock hours of annual training in 2011.
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Plan of Correction
Program Director will educate all staff on training requirements in staff meetings and supervision. All staff will receive a memo on 704.11 (f) (2). Program Director will monitor for compliance through supervision and quarterly reports from HR Director. |
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 February 1, 2012 revealed torn carpet throughout the interior of the facility. There were tears in the carpet in the group room, hallway, offices, and entrances to offices. There were seams of carpet missing that presented a potential tripping hazard. There was a cobblestone walkway that lead from the parking lot to the main entrance of the facility. The stones in this walkway were observed to be loose when walked upon, creating a potential hazard.
The findings were confirmed by the project director and were not disputed.
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Plan of Correction
Contractor has already been obtained. All rugs will be removed and replaced with tile in all areas of the clinic. Contractors have already replaced the cobblestone walkway with a wider, concrete pavement and continue to work on replacing the concrete pavement surrounding the program. Project Director will monitor for compliance through ongoing contact with facility landlord |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation, the facility failed to ensure privacy so that counseling session could not be seen or heard outside the counseling room. The findings include:
During the inspection, counseling sessions were overheard from employee # 6's office. This finding was discussed with the project director and facility director and was not disputed.
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Plan of Correction
Program director has instructed Office Manager to purchase white noise machines for all counseling offices. Program director will monitor for compliance with use of these throught direct observation. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observation, the facility failed to have soap in each bathroom, as required.
The findings include:
On January 31, 2012, the staff bathroom beside the Project Director's office was observed to not have any soap for staff and visitor use. Hand sanitizer was provided when staff were asked to provide soap. On February 1, 2012, during the physical plant tour at 8:30 am, the same bathroom was observed to not have any soap for staff and visitor use. Soap was provided for this bathroom when this area of noncompliance was addressed with staff.
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Plan of Correction
Program has ordered wall mounted soap dispensers for all bathrooms in the clinic. Soap dispensers will be mounted by 2/29/12. Office Manager or her designee will check all bathrooms to ensure that they are stocked with necessary items daily. Office Manager will monitor for compliance. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant tour, the facility failed to ensure that all heaters were permanently mounted or installed.
The findings include:
The physical plant inspection took place on February 1, 2012. Three heaters that were not permanently mounted or installed were observed during the physical plant tour. The facility director's office, the doctor's office, and one counselor's office included a heater that was not permanently mounted or installed.
The project director confirmed this finding.
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Plan of Correction
Contractor has already installed new heating and air conditioning system and replaced thermostats. All of the radiator oil type heaters have been removed from the facility. Project Director will maintain ongoing contact with landlord around any physical plant issues which could impact staff or patient safety or comfort |
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.
The findings include:
A financial audit was provided that included activities of September 2009 to July 2010. The project director was interviewed on February 1, 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 completed an audit that included the months of August 2010 through December 2010.
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Plan of Correction
Project Director has informed Board of need for 2011 audit. This will be addressed at next Board meeting in March and Project Director will follow up for compliance. Memo will be sent to Board every November reminding them of need for audit. Project Director will be responsible for sending memo of reminder to Board |
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 four of seven patient records reviewed. The facility exceeded 4 Pa. Code, Subsection 255.5(b) in one of seven records reviewed.
The findings included:
Thirteen patient records were reviewed January 31, 2012 through February 1, 2012. Seven 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 patient records reviewed, # 5, 6, 8, and 11.
A review of patient record # 5 revealed information was released to a funding source on December 6, 2011. The patient did not sign a release prior to releasing information for the funding entity.
A review of patient record # 6 revealed a letter was written "To Whom it May Concern" on October 17, 2011. A consent to release could not be verified for this letter due to the letter not being written to a specific person or entity.
A review of patient record # 8 revealed information was released to a probation officer on October 21, 2011. The patient did not sign a consent to release information for the probation officer. The facility exceeded 4 Pa. Code, Subsection 255.5(b) by releasing information to the probation officer that included type and frequency of treatment and type of medication.
A review of patient record # 11 revealed information was released to a funding source on October 11, 2011. The patient did not sign a release prior to releasing information for the funding entity.
This is a repeat citation from the December 30, 2010 licensing inspection
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Plan of Correction
Program Director will do an in service on the proper way to complete all consents. All staff will be given a detailed memo on completion of consents to use as a reference. Program Director will monitor for compliance through monthly chart audits and supervision with clinical staff. Any records in question at the time of the site visit will have appropriate consents completed and in patients charts immediately |
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 ten records reviewed.
The findings included:
Thirteen patient records were reviewed on January 31, 2012 to February 1, 2012. Ten patient records were reviewed for documentation of a drug and alcohol history that included lengths and patterns of use. Seven patient records # 1, 2, 3, 6, 7, 8 and 9 failed to document a drug and alcohol history that included lengths and patterns of use.
This finding was discussed with the facility director and clinical supervisor.
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Plan of Correction
Program Director will do an in service on the proper way to complete the psychosocial history. New biopsychosocial is being developed which will conform to DAPL guidelines. Program Director will monitor for compliance through chart audits and weekly supervision. |
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 was completed within the time frames indicated by facility policy in six of twelve patient records.
The findings include:
Thirteen patient records were reviewed on January 31, 2012 to February 1, 2012. Twelve patient records were reviewed for compliance with the facility policy. The facility policy indicated the personal history is to be completed within 30 days of admission. The facility failed to document completion of the personal history within the timeframe in patient records # 6, 7, 8, 10, 11, and 13.
Patient # 6 was admitted on August 11, 2011. The personal history documentation in patient record # 6 was not dated and it could not be determined if the documentation was completed within the required timeframe.
Patient # 7 was admitted on October 4, 2011. The personal history document was completed on January 13, 2012. The expected completion date was November 4, 2011.
Patient # 8 was admitted on June 17, 2011 and discharged on November 24, 2011. The personal history document was not dated and it could not be determined if the documentation was completed within the required timeframe.
Patient # 10 was admitted on February 7, 2011 and discharged on August 18, 2011. The personal history document was not signed or dated and it could not be determined if the documentation was completed within the required timeframe.
Patient # 11 was admitted on October 11, 2011. The personal history document was not dated and it could not be determined if the documentation was completed within the required timeframe.
Patient # 13 was admitted on November 10, 2011. The personal history was not documented as of the date of the inspection.
These findings were confirmed by the facility director and clinical supervisor.
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Plan of Correction
Program Director will do an in service training addressing the time frames indicated in the facility Policy & Procedure manual. Counseling staff will receive a detailed memo outlining the time frames for completion of all documents. Program Director will monitor for compliance through monthly chart audits and supervision. |
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 five of six patient records.
The findings include:
Thirteen patient records were reviewed on January 31, 2012 to February 1, 2012. Six 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 # 5, 7, 9, 12 and 13.
Patient # 5 was admitted on December 6, 2011. The psychosocial evaluation was due by January 6, 2011. The documentation in patient # 6"s record was not dated and it could not be determined if the documentation was completed within the required timeframe.
Patient # 7 was admitted on October 4, 2011. The psychosocial evaluation was due by November 4, 2011. The documentation in patient # 7's record was not signed or dated and it could not be determined if the documentation was completed within the required timeframe.
Patient # 9 was admitted on September 23, 2011. The psychosocial evaluation was due by October 23, 2011 and was not completed. The facility failed to document the completion of a psychosocial evaluation as of the date of the inspection.
Patient # 12 was admitted on November 8, 2011. The psychosocial evaluation was due by December 8, 2011. The documentation provided in patient #12's record was not signed or dated and it could not be determined if the documentation was completed within the required timeframe.
Patient # 13 was admitted on November 10, 2011. The psychosocial evaluation was due by December 10, 2011 and was not completed. The facility failed to document the completion of a psychosocial evaluation as of the date of the inspection.
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Plan of Correction
Program Director will do an in service training on the proper completion of the psychosocial evaluation. An interim plan is in place for all intakes to be completed at SOAR Northeast for the next 90 days. Program Director will monitor for compliance through chart audits and supervision. While the intake process is done at the Northeast site, Program Director at Chester will address any concerns with Program Director at the Northeast. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of patient records the facility failed to document an individual treatment and rehabilitation plan that included support services in four of thirteen patient records reviewed.
The findings include:
Thirteen patient records were reviewed on January 31, 2012 to February 1, 2012. All patient records were reviewed for treatment and rehabilitation plans. The facility failed to document support services in treatment and rehabilitative plans in four patient records, # 2, 3, 5 and 10.
Patient # 2 was admitted on June 30, 2011. The facility completed a treatment and rehabilitation plan on July 3, 2011. The facility failed to document support services in the treatment and rehabilitation plan.
Patient # 3 was admitted on June 24, 2011. The facility completed a treatment and rehabilitation plan on July 22, 2011. The facility failed to document support services in the treatment and rehabilitation plan.
Patient # 5 was admitted on December 6, 2011. The facility completed a treatment and rehabilitation plan on January 6, 2012. The facility failed to document support services in the treatment and rehabilitation plan.
Patient # 10 was admitted on February 7, 2011. The facility completed a treatment and rehabilitation plan on March 7, 2011. The facility failed to document support services in the treatment and rehabilitation plan.
The findings were confirmed by the facility director and clinical supervisor.
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Plan of Correction
Program director will do an in service on appropriate chart documentation as it relates to the individual treatment and rehabilitation plan. A new treatment and rehabilitation plan is being developed which will comply with all DAPL guidelines. Program Director will monitor compliance through chart audits and supervision. |
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 nine patient records reviewed.
The findings were:
Thirteen patient records were reviewed on January 31, 2012 to February 1, 2012. Nine 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 # 4, 6 and 7. New goals were identified in the treatment plan update without documentation of the progress of previous goals identified in the treatment plan.
Patient # 4 was admitted on February 11, 2011. The comprehensive treatment and rehabilitation plan was documented on February 11, 2011. The treatment and rehabilitation plan update was due on April 11, 2011 and not completed. The treatment and rehabilitation plan updates completed on June 28, 2011 and August 29, 2011 failed to include progress as it related to the current goals identified on the comprehensive treatment and rehabilitation plan. The facility documented two new goals without documenting the progress on the previous goals.
Patient # 6 was admitted on August 11, 2011. The comprehensive treatment and rehabilitation plan was documented on September 11, 2011. The treatment and rehabilitation plan updates were documented on November 11, 2011 and January 9. 2012. The facility documented new goals without documenting the progress on the previous goals.
Patient # 7 was admitted on October 4, 2011. A comprehensive treatment and rehabilitation plan was completed on November 4, 2011. A treatment and rehabilitation plan update was completed January 4, 2012. The facility documented new goals without documenting the progress on the previous goals.
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Plan of Correction
Program Director will do an in service on how to appropriately document patient progress/lack of progress to reflect in successive treatment and rehabilitation plans. A new treatment and rehabilitation plan is being developed which will follow DAPL guidelines. Program Director will monitor compliance through chart audits and supervision. |
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 all of the required information in four of four patient records.
The findings include:
Thirteen patient records were reviewed January 31, 2012 through February 1, 2012. Four patient records were reviewed for completed discharge summaries.
Patient # 2 was admitted June 30, 2011 and discharged November 8, 2011. The discharge summary was documented, but the summary did not include the services offered or the status of the patient upon discharge.
Patient # 3 was admitted June 24, 2011 and discharged October 29, 2011. The discharge summary was documented, but the summary did not include the services offered or the status of the patient upon discharge.
Patient # 8 was admitted June 17, 2011 and discharged November 24, 2011. The discharge summary was documented, but the summary did not include the status of the patient upon discharge.
Patient # 9 was admitted September 23, 2011 and discharged October 23, 2011. The discharge summary was documented, but the summary did not include the status of the patient upon discharge.
This finding was discussed with the project director and was not disputed.
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Plan of Correction
A new discharge summary form is being completed which will follow the guidelines of DAPL. Program Director will do an inservice on proper completion of discharge summary. Program Director will monitor compliance through chart audits and supervision. |