INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on December 2, 2024 through December 3, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Soar Corp was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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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 a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client record reviewed.
Client # 4 was admitted on January 7, 2019 and was administratively discharged on September 18, 2024. The client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project on September 18, 2024; however, the written notice did not include the reason for termination.
This is a repeat citation from the January 5, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/13/2024, the regional director has modified the termination letter to include a text box that will now be used to state the exact reason for the termination. The modified form is now placed in the EMR system for the clinical staff to use. A instructional memo will be sent by 12/31/2024 to the clinical staff to indicate the change in the form and the need to put the exact reason for a termination on discharge document. Ongoing the Qi department will audit the discharges monthly to ensure the exact reason for discharge is added to the document. Occurrence of missing information will be referred to the program director for correction. Process will start as of 1/2/2025 and be ongoing |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on an administrative review, the narcotic treatment program failed to ensure narcotic treatment physician services were provided at least 1 hour per week onsite for every ten patients for three weeks out of eighteen weeks reviewed.
During the week of July 1, 2024 through July 7, 2024, the patient census was 170 and required 17 physician hours, but there were zero physician hours documented during the week.
During the week of August 12, 2024 through August 18, 2024, the patient census was 172, and required 17.2 physician hours, but there were 6 physician hours documented during the week.
During the week of September 2, 2024 through September 8, 2024, the patient census was 169 and required 16.9 physician hours, but there were 6 physician hours documented during the week.
This is a repeat citation from the January 24, 2023 and January 5, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Soar is currently making an effort to hire an additional MD to extend service hours for the patients and to provide vacation coverage for the existing MD's. The CEO of Soar will be responsible for the recruitment and hiring of an additional MD within the next 90 days. The recruitment and hiring of a MD shall be ongoing. The ratio of MD hours to patient census shall be monitored by the QI department to ensure compliance |
715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to a receiving narcotic treatment program for a transferring patient in one of one applicable patient record reviewed.
Client # 5 was admitted on March 20, 2024 and was transferred to another narcotic treatment program on July 15, 2024. There was no documentation in the record indicating the exact materials that were sent to the receiving narcotic treatment program on behalf of the transferring patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Vendor of the EMR system has developed a new system in the electronic patient file to document a transfer request. All transfer outs will now be documented electronically, and shall include the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and the current status of the patient When a patient makes a transfer request, the primary counselor will send an email to the program director with 24 hours of the request. The counselor will complete the transfer documents in the emr system, sending the required documents to the outside provider within 7 days of the request. To ensure completion, the program director will audit the patient chart upon receiving a notification of transfer to ensure the documentation is complete. Occurrences of missing or incomplete document will be addressed by the program director for correction an instruction memo explaining process will be issued by 1/13/2025 by email from the regional director and the system will be used as of 1/13/2025. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient record reviewed.
Patient # 2 was transferred in from another narcotic treatment program and admitted on May 20, 2024 and was still active at the time of inspection. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the client's date of admission and the date the client was given their initial dose.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Vendor of the EMR system has developed a new system in the electronic patient file to document a transfer request All transfer in's will now be recorded and documented electronically, and shall include the initial dosing information, last dose information, admission date, dosing records. When a patient makes transfers in, the intake counselor will send an email to the program director with 24 hours of the request. The counselor will complete the transfer in documents in the emr system, sending the required documents to the outside provider within 24 hours of the admission date. To ensure completion, the program director will audit the patient chart upon receiving a notification of a transfer in to ensure the documentation is complete. Occurrences of missing or incomplete document will be addressed by the program director for correction an instruction memo explaining process will be issued by 1/13/2025 by email from the regional director and the system will be used as of 1/13/2025. |
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 client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in four of seven client records reviewed.
Client # 1 was admitted on April 16, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 14, 2024 and the first update was due no later than July 14, 2024; however, the update was completed on September 4, 2024.
Client # 2 was admitted on May 20, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 20, 2024 and the first update was due no later than July 20, 2024; however, the update was completed on August 13, 2024.
Client # 4 was admitted on January 7, 2019 and was discharged on September 18, 2024. A treatment plan update was completed on February 13, 2024 and the next update was due no later than April 13, 2024; however, the update was completed on June 18, 2024. Additionally, a treatment plan update was completed on June 18, 2024 and the next update was due no later than August 18, 2024; however, the update was completed on September 3, 2024.
Client # 5 was admitted on March 20, 2024 and was discharged on July 15, 2024. The individual treatment and rehabilitation plan was completed on March 20, 2024 and the first update was due no later than May 20, 2024; however, the update was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An instructional memo shall be issued by the regional director by 1/13/2025 to the clinical staff regarding late or missing treatment plans. The memo will state that the staff is responsible for ensuring that all treatment plans are completed prior to the end date of the current plan. The memo will state that the program director needs to run the "tx plans due in a range report 147d" weekly to identify treatment plans that are overdue or upcoming. The program director will send the report weekly to the clinical staff with a instruction to complete the plans. To ensure completion, the program director will review the tx plan reports during the supervision session and will document addressing any occurrence of late or missing plans with the counselor. The process of This plan will be in effect by 1/2/2025 and the program director will monitor to ensure poc is followed. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents and patient records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure narcotic treatment physician services were being provided at least 1 hour per week onsite for every ten patients was submitted and approved by the Department for the January 5, 2024 and January 24, 2023 annual licensing inspections. Failing to ensure narcotic treatment physician services were being provided at least 1 hour per week onsite for every ten patients was again found to be a deficiency in the December 2, 2024 through December 3, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within the next 60 days (2/13/2025) the CEO of the company shall interview and hire a Corporate Compliance Officer. The corporate compliance officer shall be responsible for overseeing the quality assurance and audit review process and for the completion of a plan of corrections from state and funding sources. The Corporate compliance officer shall provide a monthly report to the CEO and regional project director who will monitor the processes to ensure completion |