INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on January 4, 2024 through January 5, 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.
Employee # 1 has been in the position of project director since February 1, 2014. The facility's training year that was reviewed was from January 1, 2023 through December 31, 2023. Employee # 1's employee record only documented 3 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/1/2024 a instructional memo will be sent to all staff regarding trainings. The memo will state that training certificates from outside sources that do not specifically state the total hours of training will not be accepted. If a training certificate is rejected for this reason the employee will have to complete additional trainings to meet the training hours. The verification of the training hours on a certificate will be completed by the HR assistant. Quarterly the HR assistant shall email staff stating the outstanding trainings and training hours. Occurrence of missing or outstanding training shall be addressed by the supervisor. the QI assistant shall monitor the process for completion |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's February 2023 through December 2023 fire drill logs, the facility failed to ensure that a fire alarm or smoke detector was set off during each fire drill. There was no documentation that a fire alarm or a smoke detector was set off during the May 2023 fire drill conducted.
This is a repeat citation from the January 24, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 2/7/24, the regional project director will send an instructional memo to Qi department of the facility. The memo will state that all fire drills forms must be audited on a monthly basis to ensure they are completed and accurate. The process will ensure that the box for the alarm set off is indicated on the form. Occurrences of the box not being checked will be emailed to the program director for correction. Process will be ongoing and start on 2/7/24 |
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.
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Observations
Based on a review of nine client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 4 was admitted on February 15, 2023 and was discharged on July 6, 2023. The record contained documentation that the physical, labs, and dosing history were sent to another treatment provider on June 19, 2023, however, the consent to release information form to the treatment provider signed by the client on June 19, 2023, did not allow for the release of that information.
This is a repeat citation from the January 24, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director shall offer an internal training on the topic of releases and confidentiality by 2/23/24. Proof of the training shall be placed in the employees HR file in the form of a certificate. The training will cover proper release formulation in the EMR system, items to be disclosed for a patient transfer request and the need to ensure the ROI is completed prior to the disclosure of information. To ensure compliance the program director review the ROI for a transfer packet prior to information being sent. This process will start as of 2/23/24 and shall be ongoing. |
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 document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client # 3 was admitted on April 4, 2022 and was involuntarily discharged on May 23, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 2/7/24, the regional project director will send an instructional memo to Qi department of the facility. The memo will state that the patient discharges will be audited weekly by the QI assistant. The audit will ensure that the discharges have a completed termination letter and a completed discharge follow up that is completed within 30 days of the discharge date. Occurrences of incomplete or missing documents will be emailed to the program director for correction. Process will be ongoing and start on 2/7/24 |
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 the review of four months of physician and physician's assistant timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in one week reviewed.
During the week of August 14, 2023 through August 20, 2023, the patient census was 158. The facility was required to provide at least 15.8 physician hours. There were 12 hours documented.
This is a repeat citation from the January 24, 2023 annual licensing renewal inspection.
These findings were 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 |
715.6(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.
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Observations
Based on the review four months of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for one week reviewed. A physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours.
During the week of August 14, 2023 through August 20, 2023, the patient census was 158. The physician was required to provide one-third of the 15.8 hours, which equals to 5.26 hours. The physician provided 0 hours.
This is a repeat citation from the January 24, 2023 annual licensing renewal inspection.
These findings were 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 |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the narcotic treatment program failed to complete a random urinalysis at least monthly in one of nine patient records reviewed.
Patient # 4 was admitted on February 15, 2023 and was discharged on July 6, 2023. There was no documented drug screen urinalysis in the record for the month of April 2023.
This is a repeat citation from the January 24, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 1/15/2024, the nursing manager will run a "patient without a uds report" from the EMR system twice a month to identify the patients who have not completed the minimum UDS screening requirements. Patient identified by this method shall be placed on hold to complete a sample. Patients who refuse to complete the screenings shall have a non-billable medical note placed in their emr record to indicate the attempt and refusal to complete. To ensure compliance at the end of each month, the qi staff shall run "patient without a uds report" and audit the patient's chart for a nonbillable note. A chart lacking a nonbillable note shall be sent to the nursing manager for correction. The process will be ongoing as of 1/15/2024. |
715.17(c)(1)(i-vi)) 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:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure that a narcotic treatment physician determine the patient ' s initial dose and schedule in three of four applicable records reviewed.
Patient # 2 was admitted on July 20, 2023 and was active at the time of the inspection. The initial medication order was entered on July 20 2023 by a physician ' s assistant.
Patient # 6 was admitted on March 7, 2023 and was discharged on May 3, 2023. The initial medication order was entered on March 7, 2023 by a physician ' s assistant.
Patient # 8 was admitted on March 23, 2023 and was active at the time of the inspection. The initial medication order was entered on March 23, 2023 by a physician ' s assistant.
Additionally, during an observation of medication administration on January 4, 2024, one nurse was observed preparing for subsequent medication doses or take-home medication, instead of observing patients when ingesting the agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Director and the Regional Director shall send a instructional memo to the medical staff by 1/31/24 regarding methadone inductions. The memo will state that per facility's SAMHSA exemption, the P.A. can make dosing changes and complete the initial face-to-face, documentation of opiate addiction but cannot write the initial order for methadone, that the initial order must be written by a MD. To ensure plan is followed the QI will audit all new admissions within 1 week to ensure the initial order is from a MD. Occurrences of the plan not being followed will be reported to the medical director for correction |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month, 1 hour of which shall be individual psychotherapy, during each patient's first 2 years in treatment in one of seven applicable patient records reviewed.
Patient # 8 was admitted on March 23, 2023 and was active at the time of the inspection. The record of service and progress notes documented that during the months of November and December 2023, there were 0 hours of psychotherapy provided to the patient, and during the month of September 2023, there was 1 hour of psychotherapy provided to the patient.
This is a repeat citation from the January 24, 2023, January 21, 2022 and December 3, 2020 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/1/24, the program director will run the "the patients not counseled report" weekly to identify patients who have not completed their scheduled therapy sessions. Once identified the patients will be placed on a dose hold to complete the session with their counselor. if the patient elects to not complete the session, the counselor shall place a non-billable note in the system to state as such. The weekly check of services will be ongoing by the program director to ensure the 2.5 hours of psychotherapy are met. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to ensure an annual physical examination was given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in one of five applicable records reviewed.
Patient # 5 was admitted on July 6, 2020 and was discharged on August 15, 2023. The annual physical examination was due no later than July 6, 2023; however, the most recent annual physical was completed on June 27, 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The regional project director and Soar's EMR vendor to have built an audit tool and report for patient - MD physical report within the EMR system. The audit report will identify patient MD physical annuals that will be due within 30 days of running the report and will also identify any late reviews. Weekly the patient MD Physical report will be run by the clinical supervisor and patients due for a annual will be scheduled by the medical administrative staff. A management team member will document non-compliance with attending a annual review in the patient's emr file so serve as proof attempts to complete the review were made by the facility. The process will be monitored by the QI department to ensure completion. The process of completing the weekly audit report will begin as of 1/15/2024 and be ongoing |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor in three of three applicable patient records reviewed.
Patient # 3 was admitted on April 4, 2022 and was discharged on May 23, 2023. The annual evaluation of the patient's status was due to be completed by the counselor by April 4, 2023; however, the record did not contain documentation of an annual evaluation.
Patient # 5 was admitted on July 6, 2020 and was discharged on August 15, 2023. The annual evaluation of the patient's status was due to be completed by the counselor by July 6, 2023; however, the record did not contain documentation of an annual evaluation.
Patient # 7 was admitted on November 10, 2022 and was active at the time of the inspection. The annual evaluation of the patient's status was due to be completed by the counselor by November 10, 2023; however, the evaluation was not completed until November 28, 2023.
This is a repeat citation from the January 24, 2023 and January 21, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
the regional project director and Soar's EMR vendor to have built an audit tool and report for patient clinical annuals within the EMR system. The audit report will identify patient clinical annual that will be due within 30 days of running the report and will also identify any late reviews. Weekly the patient clinical annual report will be run by the clinical supervisor and the report will be sent to the clinical staff by email. The clinical supervisor will discuss outstanding clinical annuals identified by this manner in the supervision sessions. The process will be monitored by the QI department to ensure completion. The process of completing the weekly audit report will begin as of 1/15/2024 and be ongoing |
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 a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in three of four applicable client records reviewed.
Client # 4 was admitted on February 15, 2023 and was discharged on July 6, 2023. The individual treatment and rehabilitation plan was completed on February 15, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 6 was admitted on March 7, 2023 and was discharged on May 3, 2023. The individual treatment and rehabilitation plan was completed on April 5, 2023; however, the plan did not include documentation of the proposed type of support services.
Client # 8 was admitted on March 23, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 19, 2023; however, the plan did not include documentation of the proposed type of support services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director will complete a training on treatment plans with clinical staff by 2/23/24. The training will focus on the development of sober support in the treatment plan and how to enter this into the treatment plan post training the program director will review the treatment plans prior to signing to ensure the supports are noted. Reviews of the plans for support will begin as of 2/23/34 and be ongoing. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in eight of nine records reviewed.
Client # 2 was admitted on July 20, 2023 and was active at the time of the inspection. The treatment plans completed on August 21, 2023, October 19, 2023, and December 19, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of an individual session the weeks of September 11, 2023, October 9, 2023, and November 13, 2023.
Client # 3 was admitted on April 4, 2022 and was discharged on May 23, 2023. The treatment plans completed on January 3, 2023 and March 6, 2023, indicated that the client was to receive one individual session and one group session per week; however, the record contained no documentation of an individual session the weeks of February 27, 2023 and March 13, 2023. Additionally, the record contained no documentation of group sessions in the month of February 2023.
Client # 4 was admitted on February 15, 2023 and was discharged on July 6, 2023. The treatment plan completed on April 4, 2023, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between April 4, 2023 and April 27, 2023.
Client # 5 was admitted on July 6, 2020 and was discharged on August 15, 2023. The treatment plans completed on March 29, 2023, May 30, 2023, and July 19, 2023, indicated that the client was to receive one individual session and one group session per week; however, the record did not contain documentation of individual sessions between May 10, 2023, and June 7, 2023. Additionally, the record only contained documentation of one group session in the month of July 2023.
Client # 6 was admitted on March 7, 2023 and was discharged on May 3, 2023. The treatment plans completed on March 7, 2023 and April 5, 2023, indicated that the client was to receive one group session per week; however, the record did not contain documentation of group sessions for the month of April 2023.
Client # 7 was admitted on November 10, 2022 and was active at the time of the inspection. The treatment plans completed on October 2, 2023 and November 28, 2023, indicated that the client was to receive one group session per week; however, the record did not contain documentation of a group session the week of November 27, 2023.
Client # 8 was admitted on March 23, 2023 and was active at the time of the inspection. The treatment plans completed on August 24, 2023, October 24, 2023, and December 20, 2023, indicated that the client was to receive one individual session and one group session per week; however, the record did not contain documentation of group sessions for the months of September, October, November, or December 2023. Additionally, the record did not contain documentation of individual sessions during the months of November and December 2023.
Client # 9 was admitted on October 12, 2018 and was active at the time of the inspection. The treatment plan completed on October 13, 2023, indicated that the client was to receive one individual session per week; however, the record did not contain documentation of individual sessions for the month of November 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director shall complete a training with the clinical staff of the facility on the topic of treatment and rehabilitation services. The training shall be offered by 2/23/24. The training will focus on methods to ensure counseling services are provided according to the individual treatment and rehabilitation plan. The training focus on ways to document a patient who is non-compliant with their treatment and rehabilitation services as outlined in their treatment plan. The training will also focus on the need up updated the indicated frequency of group and individual attendance on a patient's treatment plan to reflect current requirements. Post training, the program director / clinical supervisor will run a "patient not counseled report" to identify the patients who have missed therapy sessions. The clinical supervisor will cross check the system to ensure the n these non-billable notes are entered. Occurrences of a missed session note not being present shall be addressed by the supervisor and a correction by the counselor shall be completed. Monitoring shall begin on 2/23/24 after the training is completed |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every three months for the first year of treatment and annually thereafter, per the facility's policy, in seven of eight applicable records reviewed.
Client # 2 was admitted on July 20, 2023 and was active at the time of the inspection. The first case consultation note was due to be completed by October 20, 2023; however, it was not documented until November 2, 2023.
Client # 3 was admitted on April 4, 2022 and was discharged on May 23, 2023. The twelve-month case consultation note was due to be completed by April 4, 2023; however, the most recent case consultation note was documented on January 4, 2023.
Client # 4 was admitted on February 15, 2023 and was discharged on July 6, 2023. The record did not contain documentation of case consultation notes.
Client # 5 was admitted on July 6, 2020 and was discharged on August 15, 2023. The annual case consultation note was due to be completed by July 6, 2023; however, the most recent case consultation note was completed on July 6, 2022.
Client # 7 was admitted on November 10, 2022 and was active at the time of the inspection. A case consultation note was documented on March 29, 2023, and the next case consultation note was due to be completed by June 29, 2023; however, no subsequent case consultation notes were completed prior to the inspection.
Client # 8 was admitted on March 23, 2023 and was active at the time of the inspection. A case consultation note was documented on June 22, 2023, and the next case consultation note was due to be completed by September 22, 2023; however, no subsequent case consultation notes were completed prior to the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Soar's regional project director has changed its own internal policy 60002 regarding case conference notes. The modification will now read "Case Consultation Notes- Case Consults are done at the 6 month point from the point of admission. Additional case conference notes shall be entered on a as needed basis." A copy of the revised policy will be issued to the clinical staff as of 1/15/2024. Ongoing, to ensure the case consults are completed timely, the QI Assistant on a monthly basis will run the admission for the last 6 months report to identify upcoming consults that will be due. Once identified, the QI assistant will send a report to the clinical staff by email. The clinical supervisor will discuss the completion of and the need to complete any outstanding case consults in the supervision sessions. The process will be monitored by the QI assistant to ensure completion. The process of completing the weekly audit report will begin as of 1/15/2024 and be ongoing. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information at 30- and 90-days post discharge, per facility policy, in three of five applicable records reviewed.
Client # 3 was admitted on April 4, 2022 and was discharged on May 23, 2023. The client record did not contain documentation of follow-up information.
Client # 4 was admitted on February 15, 2023 and was discharged on July 6, 2023. The client record did not contain documentation of follow-up information.
Client # 5 was admitted on July 6, 2020 and was discharged on August 15, 2023. The client record did not contain documentation of follow-up information.
This is a repeat citation from the January 24, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/11/23, Soar's regional project director has changed its own internal policy 60002 regarding case discharge follow up. The modification will now read All members who have been discharged will, with the written consent of the member, receive a follow up attempt from the program to determine the member's disposition. The members will be contacted within in thirty (30) days after their discharge date". As of 12/11/23, an instructional email has been issued by the regional director to the clinical staff. The instructional email states timelines for follows and reviews the process to document the follow in the EMR system. The QI Assistant will run the discharge follow up report in the emr system to identify missing or incomplete follow ups. Once identified, the QI assistant will send a report to the clinical staff by email. The clinical supervisor will discuss outstanding follow ups in the supervision sessions. The process will be monitored by the QI assistant to ensure completion. The process of completing the weekly audit report will begin as of 1/15/2024 and be ongoing. |
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 provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was submitted and approved by the Department for the January 24, 2023, January 21, 2022 and December 3, 2020 annual licensing inspections. Failing to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was again found to be a deficiency in the January 4, 2024 through January 5, 2024 licensing inspection.
A plan of correction for completing annual counselor evaluations, reviewed and signed by the physician, was submitted and approved by the Department for the January 24, 2023 and January 21, 2022 annual licensing inspections. Failing to complete annual counselor evaluations was again found to be a deficiency in the January 4, 2024 through January 5, 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 3/11/2024 the company shall interview and hire a Quality Assurance staff member. The current and additional QI staff shall be responsible for audit review of current and discharge client records, and monitoring the completion of a plan of corrections from state and funding sources. The QI staff shall provide a monthly report to the CEO and regional project director who will monitor the processes to ensure completion
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