INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on February 4, 2020 through February 6, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, SOAR CORP was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
During a licensing inspection conducted on February 4, 2020 through February 6, 2020, the project failed to ensure that counselor assistants counseled clients under the close supervision of a trained counselor or clinical supervisor for the supervision periods outlined in this regulation.Employee #5, with a high school diploma, was hired as a counselor assistant on March 20, 2019 and remained in this position at the time of the inspection. There was no documentation that this employee was under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. Additionally, there was no documentation indicating that this counselor assistant received close supervision; one hour of case review and one hour of direct observation for the months of July 2019 through January 2020. Employee #6, with a qualifying Bachelor's Degree, was hire as a counselor assistant on February 4, 2019 and remained in this position at the time of the inspection. There was no documentation indicating that this counselor assistant received close supervision; one hour of case review and one hour of direct observation for the months of February 2019 through August 2019.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The program director shall complete an in-house training with the clinical supervisors of the program to review the standards and documentation procedures for an assistant counselor. The training will provide instructions on how to provide documentation indicating that the counselor assistant received close supervision; one hour of case review and one hour of direct observation the in house training shall be completed within the next 30 days (3/17/2020). Post training, the program director shall review the clinical supervision notes completed by the clinical supervisor to ensure that the time, date and session type of the direct observation is documented within the note. The program director shall review the supervision notes to ensure that the date, time and duration of a case review is noted within the supervision note of an assistant counselor. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
During a licensing inspection conducted on February 4, 2020 through February 6, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Client #4 was admitted on October 4, 2019 and was a current client at the time of the inspection. There was documentation of communication with another provided in this client's record; however, there was no proper consent to release information form signed by the client prior to disclosure.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The program director shall complete an internal training with the clinical staff of the facility regarding the 709.28 Confidentiality regulations. The training shall be completed within the next 30 days (3/17/2020). The training shall cover the requirements for establishing a proper signed consent to release information form by the client prior to disclosure. Items covers will be establishing proper witness and client signatures, stating the information to be disclosed, and stating the name of the person, agency or organization to whom disclosure is made. The training will also cover a review of the 255.5 regulations for confidentiality to discuss when a ROI is needed and the 5 domains of information that can be released. The proof of training shall be placed in the HR file of each Staff. Ongoing, the clinical supervisor shall complete chart audits to review releases to ensure compliance with the training. This review process by the supervisor shall be ongoing. The program Director shall request Client 4 to sign a current ROI being referenced in the finding within the next 2 weeks (3/2/2020) |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
During a licensing inspection conducted on February 4, 2020 through February 6, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included documentation of the name of the person, agency or organization to whom disclosure will be made. Client # 8 was admitted on November 4, 2019 and was a current client at the time of the inspection. The client's record contained an informed and voluntary consent form for an emergency contact. The consent form was signed by the client on November 4, 2019; however, the name of the emergency contact was not documented on the form.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The program director shall complete an internal training with the clinical staff of the facility regarding the 709.28 Confidentiality regulations. The training shall be completed within the next 30 days (3/17/2020). The training shall cover the requirements for establishing a proper signed consent to release information form by the client prior to disclosure. Items covers will be establishing proper witness and client signatures, stating the information to be disclosed, and stating the name of the person, agency or organization to whom disclosure is made. The training will also cover a review of the 255.5 regulations for confidentiality to discuss when a ROI is needed and the 5 domains of information that can be released. The proof of training shall be placed in the HR file of each Staff. Ongoing, the clinical supervisor shall complete chart audits to review releases to ensure compliance with the training. This review process by the supervisor shall be ongoing. The program Director shall request Client 8 to the emergency contact on the ROI being referenced in the finding within the next 2 weeks (3/2/2020) |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
During a licensing inspection conducted on February 4, 2020 through February 6, 2020, the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #1.Client #1 was admitted on July 16, 2019 and was discharged on January 27, 2020. The client's discharge summary and aftercare plan were faxed to a government official on January 27, 2020.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The program director shall complete an internal training with the clinical staff of the facility regarding the 709.28 Confidentiality regulations. The training shall be completed within the next 30 days (3/17/2020). The training shall cover the requirements for establishing a proper signed consent to release information form by the client prior to disclosure. Items covers will be establishing proper witness and client signatures, stating the information to be disclosed, and stating the name of the person, agency or organization to whom disclosure is made. The training will also cover a review of the 255.5 regulations for confidentiality to discuss when a ROI is needed and the 5 domains of information that can be released. The proof of training shall be placed in the HR file of each Staff. Ongoing, the clinical supervisor shall complete chart audits at the time of discharge, to review releases to ensure compliance with the training. |
709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
|
Observations
During a licensing inspection conducted on February 4, 2020 through February 6, 2020, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated signature of a witness. Client #1 was admitted on July 16, 2019 and was discharged on January 27, 2020. The client's record contained two consent forms signed by the client on January 27, 2020; one for court officials and the other for a service provider. Neither consent form had a dated witness signature documented.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The program director shall complete an internal training with the clinical staff of the facility regarding the 709.28 Confidentiality regulations. The training shall be completed within the next 30 days (3/17/2020). The training shall cover the requirements for establishing a proper signed consent to release information form by the client prior to disclosure. Items covers will be establishing proper witness and client signatures, stating the information to be disclosed, and stating the name of the person, agency or organization to whom disclosure is made. The training will also cover a review of the 255.5 regulations for confidentiality to discuss when a ROI is needed and the 5 domains of information that can be released. The proof of training shall be placed in the HR file of each Staff. Ongoing, the clinical supervisor shall complete chart audits at the time of discharge to review releases to ensure compliance with the training. |
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.
|
Observations
During a licensing inspection conducted on February 4, 2020 through February 6, 2020, the project failed to notify a client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project.Client #11 was admitted on February 19, 2018 and treatment was involuntarily terminated on July 1, 2019. The project failed to notify this client, in writing, of the decision to involuntarily terminate the client's treatment.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The program director shall complete an internal training on the involuntarily termination discharge process within the next 15 days (3/2/2020). The training shall include proper completion of the involuntary termination notice including the witness and patient signature, documenting that the client was informed of their grievance process and documenting the patient was informed of the reason for the involuntary discharge. The training will also discuss the procedure to document times when a patient refuses to sign the notice of involuntarily termination. Ongoing, the clinical supervisor shall complete chart audits at the time of involuntary discharge to review the termination paperwork to ensure compliance with the training. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
During a licensing inspection conducted on February 4, 2020 through February 6, 2020, the program failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.During the week of November 24, 2019 through November 30, 2019, the patient census was 157. The facility was required to provide at least 15.7 physician hours. There were 6 physician hours documented. During the week of December 1, 2019 through December 7, 2019, the patient census was 154. The facility was required to provide at least 15.4 physician hours. There were 8 physician hours documented. These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
Soar shall continue its effort to hire an additional full time Agency MD to have vacation coverage for the existing MD's and additional hours for patient services. Interviews with several MD's are currently being processed for the identified issue. The CEO of Soar will continue be responsible for the recruitment and hiring of an additional Agency MD. The regional project director shall monitor the MD's hours by completing time sheet reviews bi-weekly to ensure compliance. The regional project director shall make a request to add additional MD hours to the CEO. The recruitment and hiring of a MD shall be ongoing by the CEO. In addition, as of 10/31/19, Soar Corp has hired an additional CRNP on a full time basis. Moving forward, during times of a MD vacation, this CRNP will provide patient care and coverage at this location. The additional CRNP staff will help to bring the facility into compliance for vacation coverage. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
|
Observations
During a licensing inspection conducted on February 4, 2020 through February 6, 2020, the program failed to ensure one-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician.During the week of October 20, 2019 through October 26, 2019, the patient census was 155. The facility was required to provide at least 15.5 physician hours; 5.22 were to be covered by a narcotic treatment physician. There were no documented physician hours for this week. During the week of December 22, 2019 through December 28, 2019, the patient census was 155. The facility was required to provide at least 15.5 physician hours; 5.22 were to be covered by a narcotic treatment physician. There were no documented physician hours for this week. These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
Soar shall continue its effort to hire an additional full time Agency MD to have vacation coverage for the existing MD's and additional hours for patient services. Interviews with several MD's are currently being processed for the identified issue. The CEO of Soar will continue be responsible for the recruitment and hiring of an additional Agency MD. The regional project director and the Human Resource Director shall monitor the MD's and CRNP's hours by completing time sheet reviews bi-weekly. The monitoring shall ensure that 1/3 of all physician hours are covered by a narcotic treatment physician and that the CRNP shall only account for 2/3 of all physician hours are covered. The monitoring and recruitment process shall be onging |
715.17(c)(3)(i-v) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
|
Observations
During a physical site inspection on February 6, 2020 and review of narcotic treatment records, the narcotic treatment program failed to inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations.The last quarterly inspection of the drug storage areas and the dispensing station was documented in February 2019. These findings were reviewed with the program staff during the licensing process.
|
Plan of Correction
The nurses on duty will continue to complete daily, weekly, monthly and quarterly dosing and inventory control inspections that are recorded within the binders in the nursing station. The nurse manager will continue to have the medication pumps calibrated on a monthly basis and record the reports within a calibration book within the nursing station. Ongoing a nurse shall document quarterly an inspection of the drug storage areas and the dispensing station on the quarterly inspection form located in the nursing station. The nurse manager shall be responsible to ensure completion. Documentation shall begin within the next 30 days and be ongoing quarterly (3/17/2020) |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
During a licensing inspection conducted on February 4, 2020 through February 6, 2020, the project failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in 5 out of 17 records reviewed.Client # 1 was admitted on July 16, 2019 and was discharged on January 27, 2020. The comprehensive treatment plan and updates, dated August 16, 2019, October 16, 2019 and December 16, 2019, indicated the client was to receive four individual sessions per month and four group session per month. The record of service and progress notes indicated that the client failed to receive four individual session for the month of August, three individual sessions for the months of September, November and December and one individual session for the month of October. Additionally, the record of service and progress notes indicated that the client failed to receive three group sessions for the month of October and December, two for the months of September and one for the month of November. Client # 3 was admitted on August 26, 2019 and was a current client at the time of the inspection. The comprehensive treatment plan and updates, dated September 26, 2019, November 26, 2019 and January 26, 2020, indicated the client was to receive four individual sessions per month and four group session per month. The record of service and progress notes indicated that the client failed to receive three individual sessions for the month of December and two individual sessions for the months of September, October, November and January. Client # 6 was admitted on July 17, 2019 and was discharged November 30, 2019. The comprehensive treatment plan, dated July 17, 2019, indicated the client was to receive four individual sessions per month and four group session per month. The record of service and progress notes indicated that the client failed to receive four individual sessions for the month of November, three individual sessions for the months of August and September and two individual sessions for the month of October. Additionally, the record of service and progress notes indicated that the client failed to receive four group sessions for the month of November.Client # 13 was admitted on May 22, 2012 and was a current client at the time of the inspection. All comprehensive treatment plan updates, dated February 18, 2019 through December 18, 2019, indicated the client was to receive four individual sessions per month and four group session per month. The record of service and progress notes indicated that the client failed to receive three individual sessions for the month of November, two individual sessions for the months of August, September, December and January. Additionally, the record of service and progress notes indicated that the client failed to receive two group sessions for the months of August through January.Client # 16 was admitted on September 4, 2018 and was a current client at the time of the inspection. The comprehensive treatment plan and update, dated October 3, 2019 and December 3, 2019, indicated the client was to receive eight individual sessions per month and nine group session per month. The record of service and progress notes indicated that the client failed to receive five individual sessions for the months of November and January and three individual sessions for the month of October. Additionally, the record of service and progress notes indicated that the client failed to receive eight group sessions for the months of January, five group sessions for the month of November and four group sessions for the month of October.These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The program counselors will write a monthly non-billable note to reflect significant gaps of service, non- compliance with treatment and any interventions implemented. The monthly update form shall document periods of being AWOL from the program, the number and dates of missed group and individual sessions. The program director shall be responsible for monitoring and compliance. The new system will be in effect within 30 days 3/17/2020 to allow notification of staff |