INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 26, 2026 through August 27, 2026 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:
|
Plan of Correction
|
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.
|
Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed.At the time of the inspection, conducted on August 27, 2026 at approximately 10:15 am, there was a portable space heater located in a second-floor counseling office that was across from the staff kitchen area.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
An all-staff email memo was issued on September 10, 2026 by the regional director, restricting the use of portable space heaters and directing their immediate removal from the facility. The space heater cited has already been removed. Moving forward, Program Directors will conduct quarterly office audits to ensure full compliance. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.There was no financial audit completed for the project's fiscal years ending June 30, 2024 and June 30, 2025 as of the date of the inspection.This is a repeat citation from the August 8, 2025 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The CEO is responsible for overseeing the project's financial audit for the fiscal year ending June 30, 2025, and shall obtain Board approval and execute a contract with an external accounting firm within 30 days. The Board President and the CEO shall jointly oversee the audit process, ensuring all required materials are submitted to the external CPA and securing final delivery of the completed audit within 90 days (by December 14, 2026). On an ongoing basis, the Board President and the CEO are responsible for ensuring all subsequent audits are completed and submitted to the Regional Director and regulatory bodies as requested. |
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to document the results of all annual physical examinations given by the narcotic treatment program, which is to include an annual reevaluation by the narcotic treatment physician, in one of six applicable patient records reviewed.Patient # 6 was admitted on July 14, 2022 and was still active at the time of the inspection. The most recent annual physical examination was completed on July 22, 2025 and the next annual physical was due to be completed by July 22, 2026; however, there was no updated physical exam documented in the record at the time of the inspection. This is a repeat citation from the August 8, 2025 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
On September 10, 2026, the Regional Director issued an all-staff email regarding the documentation process for annual physical reevaluations. Effective immediately, the Medical Receptionist must complete a Missed Session Note whenever a patient fails to attend a scheduled annual reevaluation. This document serves as proof that the appointment was scheduled, an attempt was made to complete the session, and a follow-up appointment was arranged. The completed form will be placed in the patient's record to document compliance efforts. The Program Director will review the monthly list to ensure this process is strictly followed. The patients referenced will have a physical scheduled within the next 30 days (10/14/2026) and the results will be placed in the chart |
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and was reviewed, dated and signed by the medical director in all five applicable patient records reviewed. Patient # 1 was admitted on April 13, 2016 and was discharged on June 29, 2026. There was no annual evaluation of the patient's status completed by the counselor documented in the record at the time of the inspection.Patient # 2 was admitted on November 7, 2014 and was discharged on April 16, 2026. There was no annual evaluation of the patient's status completed by the counselor documented in the record at the time of the inspection.Patient #4 was admitted on January 3, 2024 and was discharged on June 16, 2026. There was no annual evaluation of the patient's status completed by the counselor documented in the record at the time of the inspection.Patient #5 was admitted on August 15, 2025 and was active at the time of inspection. There was no annual evaluation of the patient's status completed by the counselor documented in the record at the time of the inspection.Patient #6 was admitted on July 14, 2022 and was still active at the time of the inspection. There was no annual evaluation of the patient's status completed by the counselor documented in the record at the time of the inspection.This is a repeat citation from the August 14, 2024 and August 8, 2025 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Per the Regional Director's directive issued September 11, 2026, effective September 21, 2026, all facilities will implement an ongoing weekly audit process for Clinical Annuals to ensure chart compliance. Every Monday morning, support staff will run the active patient report to verify that a complete Clinical Annual is present in each chart and signed on or before the patient's admission anniversary date. Support staff will compile a list of all missing or incomplete Clinical Annuals and forward the report directly to the Program Director. The Program Director will review the report and instruct the assigned counselor to resolve all documentation deficiencies within one week (7 calendar days) of notification. Exactly one week following notification, support staff will conduct a re-audit of the flagged records to confirm completion. The Program Director retains overall oversight of this recurring workflow to ensure long-term compliance. The patients referenced will have the annual evaluation completed within the next 30 days and the results will be placed in the chart |
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.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in six of six applicable client records reviewed. Client # 1 was admitted on April 13, 2016 and was discharged on June 29, 2026. There were no case consultation notes documented in the record at the time of inspection.Client # 2 was admitted on November 7, 2014 and was discharged on April 16, 2026. There were no case consultation notes documented in the record at the time of inspection.Client # 3 was admitted on March 23, 2022 and was discharged on February 19, 2026. There were no case consultation notes documented in the record at the time of inspection.Client # 4 was admitted on January 3, 2024 and was discharged on June 16, 2026. There were no case consultation notes documented in the record at the time of inspection.Client # 5 was admitted on August 15, 2025 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of inspection.Client # 6 was admitted on July 14, 2022 and was active at the time of inspection. There were no case consultation notes documented in the record at the time of inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Case Conference and Consultation policy will be revised to align operational guidelines with actual clinical necessity and event-driven triggers. The Regional Project Director will update the current Case Conference / Consultation Policy to remove mandatory 6-month and annual review requirements. The revised policy will specify that Case Consultations and Case Conferences are to be documented as needed and upon issuance of behavioral contracts. The revised policy draft must be finalized and formally submitted to DDAP for state approval within 30 days of this notice. |
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.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of a discharge summary, in two of four applicable client records reviewed.Client # 3 was admitted on March 23, 2022 and was discharged on February 19, 2026. There was no discharge summary documented in the record at the time of the inspection. Client # 4 was admitted on January 3, 2024 and was discharged on June 16, 2026. There was no discharge summary documented in the record at the time of the inspection. This is a repeat citation from the August 8, 2025 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On September 11, 2026, the Regional Director issued an all-staff email regarding the audit process for discharges. Support staff shall run the discharge report weekly on Mondays and examine each discharged patient's record to ensure the termination letter, discharge summary, and follow-up letters are complete and present. A list of missing documents will be sent to the Program Director, who will instruct the assigned counselor to complete the necessary corrections within one week of notification. Support staff will conduct a follow-up audit after one week to verify completion. This process will start 9/21/2026 and will be ongoing, monitored directly by the Program Director. |
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.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in four of four applicable client records reviewed. Client # 1 was admitted on April 13, 2016 and was discharged on June 29, 2026. There was no follow-up information documented in the record at the time of the inspection.Client # 2 was admitted on November 7, 2014 and discharged on April 16, 2026. There was no follow-up information documented in the record at the time of the inspection.Client # 3 was admitted on March 23, 2022 and discharged on February 19, 2026. There was no follow-up information documented in the record at the time of the inspection.Client # 4 was admitted on January 3, 2024 and discharged on June 16, 2026. There was no follow-up information documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On September 11, 2026, the Regional Director issued an all-staff email regarding the audit process for discharges. Support staff shall run the discharge report weekly on Mondays and examine each discharged patient's record to ensure the termination letter, discharge summary, and follow-up letters are complete and present. A list of missing documents will be sent to the Program Director, who will instruct the assigned counselor to complete the necessary corrections within one week of notification. Support staff will conduct a follow-up audit after one week to verify completion. This process will start 9/21/2026 and will be ongoing, monitored directly by the Program Director. |
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.
|
Observations
Based on a review of patient records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for failing to document the annual evaluation of the patient's status was submitted and approved by the Department for the August 14, 2024, and August 8, 2025 annual licensing inspections. Not documenting the annual evaluation of the patient's status was again found to be a deficiency in the August 27, 2026 licensing inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The regional project director has recommended the creation and on boarding of a dedicated Quality Assurance position to the CEO. The CEO will secure formal Board of Directors approval for the Quality Assurance position within 30 days. The CEO will oversee recruitment to hire and onboard a qualified candidate within 90 days of initial directive issuance. The QI Assistant will perform ongoing audits weekly of all Plans of Care to ensure strict regulatory and internal compliance. The QI Assistant Monitor and verify that all administrative and clinical follow-up actions related to corrective plans are fully executed. The QI Assistant will partner directly with the Program Director to redirect counselors and resolve outstanding documentation deficiencies. This process will start within 90 days and be ongoing |