INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on January 21, 2020 through January 23, 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:
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Plan of Correction
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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.
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Observations
During a licensing inspection conducted on January 21, 2020 through January 23, 2020, the project failed to ensure that counselor assistants with a bachelor ' s degree counseled clients under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
Employee # 10 was hired on August 26, 2019 and was a current employee at the time of the licensing 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 September, October, November, December and January.
Employee # 11 was hired on April 2, 2019 and was a current employee at the time of the licensing 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 April, May, June, July, August and September.
These findings were reviewed with project staff during the licensing process.
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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 (3/10/2020). 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. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
During a licensing inspection conducted on January 21, 2020 through January 23, 2020, it was determined that the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The written fire drill record does not indicate whether the smoke detectors were operative for all fire drills conducted in 2019.
The fire drill conducted in October 2019 does not indicate the number of persons in the facility at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director shall complete an internal training on fire drills and the proper documentation of the drill by 2/21/2020. Post training, the program director shall review each drill form to ensure it is complete. Any corrections shall be completed within 1 week of the review. This process will be ongoing. As of 2/10/2020, the regional project director has modified and updated the current fire drill form to include a statement indicating that the Fire Alarm, Detectors, and Equipment were Heard and Operational. As of 2/10/2020, the regional project director emailed the updated form to each site director with instructions to use immediately. Each site director shall monitor to ensure the proper form is being used to document the drills |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
During a licensing inspection conducted on January 21, 2020 through January 23, 2020, the project failed to secure hard copy client records within locked storage containers as four client records were left unattended in an unlocked conference room.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The program director shall issue a written memo by 2/17/2020 to all staff regarding the need to secure client records within locked storage containers. The memo shall be e-mailed to serve as proof of completion. The memo shall state during an onsite inspection any client records pulled and placed in a conference room for a reviewer shall not be unattended or left in an unlocked conference room. The memo shall instruct staff to close and lock a conference room door being used to review client records during times when the inspector or reviewer is not in the room. The program director and Clinical Supervisors shall be responsible to ensure the review rooms are locked and the memo is followed. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
During a licensing inspection conducted on January 21, 2020 through January 23, 2020, it was determined that the project failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving events at the facility requiring the presence of police, fire or ambulance personnel.
There was no documentation that the project reported an unusual incident occurring on August 2, 2019 that required the presence of ambulance personnel.
There was no documentation that the project reported an unusual incident occurring on August 21, 2019 that required the presence of ambulance personnel.
There was no documentation that the project reported an unusual incident occurring on August 30, 2019 that required the presence of ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director of the site shall complete onsite training with all staff regarding incident reporting. The training shall cover the types of incidents that need to be reported, the time period to report incidents and the methods to report the incidents. The training shall be completed within the next 30 days (3/10/2020) and proof shall be kept in the HR file of each employee. Ongoing, staff will notify the program director of a reportable incident on the same day it occurs. The program director shall file a report of an incident to the state and funding sources within 24 hours of being notified by staff. The program director shall be responsible to ensure that incident reports are completed and filed in a timely manner
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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
During a licensing inspection conducted on January 21, 2020 through January 23, 2020, it was determined that the program failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
The weekly census for November 25, 2019 through November 29, 2019 was 312. The program should have provided 31.2 narcotic treatment physician services hours; however, the program provided 15.5 narcotic treatment physician services that week.
The weekly census for December 23, 2019 through December 27, 2019 was 301. The program should have provided 30.1 narcotic treatment physician services hours; however, the program provided 22 narcotic treatment physician services that week.
The weekly census for December 30, 2019 through January 3, 2020 was 298. The program should have provided 29.8 narcotic treatment physician services hours; however, the program provided 21 narcotic treatment physician services that week.
These findings were reviewed with program staff during the licensing process.
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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. It is hoped this can be achieved within the next 30 days. 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. |
715.20(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
During a licensing inspection conducted on January 21, 2020 through January 23, 2020, it was determined that the program failed to 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.
Patient #17 was admitted on January 9, 2020 and was an active patient at the time of the inspection. There was no documentation that the program notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The program Director shall complete an in house training within the next 15 days (2/24/2020) regarding patient transfers. The training shall include all items to be included within the transfer package, including the psychosocial and ensuring the valid release is part of the transfer packet. The training will cover the need to fax all items to the receiving clinic and keeping the transfer coversheet and fax confirmation as proof of items sent. The training will cover how to 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. Ongoing, the clinical supervisor shall review all transfer packets prior to being sent to another provider to ensure the packet is complete. The clinical supervisor shall also review all transfers in and out of the facility to ensure first and last doses are documented. This review process by the supervisor shall be ongoing. |
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
During a licensing inspection conducted on January 21, 2020 through January 23, 2020, it was determined that the program failed to document the results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
Patient #13 was admitted on November 8, 2016 and was discharged on December 11, 2019. The last annual physical examination was completed on November 8, 2018 and the next annual physical examination was due no later than November 8, 2019; however, there was no annual physical examination documented in this patient's record at the time of the inspection.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The program director shall issue a written memo by 3/2/2020 regarding the physical annual reviews. Memo shall state that all annual reevaluation by the narcotic treatment physician must be completed by the admission date anniversary of a client. The memo shall instruct staff to have all annual reevaluations scheduled 2 weeks prior to the anniversary date. To document patient non-compliance with attending scheduled annual reevaluations, a non-billable note shall be placed within the medical section of the chart indicating the scheduled date for the annual reevaluation, the patient missing the session and when the annual reevaluation is rescheduled for. The program director shall monitor to ensure the appointments are scheduled and the no show non-billable note are entered. Process will be ongoing. |