INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 8, 2020 through December 10, 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
The project failed to ensure that a counselor assistant with a bachelor ' s degree counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first six months of employment.
Employee #4 was employed as a counselor assistant on August 18, 2020 and was a current employee at the time of the inspection. Employee #4 is to receive close supervision, which includes one hour of case review and one hour of direct observation per week until February 18, 2021; however there is no documentation in the supervision logs that this employee had ever received one hour of direct observation per week.
This is a repeat citation from an inspection conducted on January 23, 2020.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The regional project director shall complete an instructional memo to the clinical supervisor and program director to review the standards and documentation procedures for an assistant counselor. The memo shall be emailed to all referenced as proof of completion. 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 (1/21/2021). 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. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on the review of eight personnel records the project failed to ensure that employees #6, #7 and #8 receive a minimum of six hours of HIV/AIDS and at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the first year of employment.
Employee #6 was hire as a counselor on June 10, 2019 and was due to have the communicable disease trainings no later than June 10, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #7 was hire as a counselor on August 28, 2019 and was due to have the communicable disease trainings no later than August 28, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
Employee #8 was hire as a counselor on April 2, 2019 and was due to have the communicable disease trainings no later than April 2, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Employee six, seven and eight shall be scheduled to complete the training either by a in person session or virtual session within the next 60 days (2/21/2021). The program director shall monitor employees six, seven and eight for completion and a copy of the training certificate will be placed in the employee's hr file. Ongoing, the program director will ensure that new staff locate and attend the required training within the outlined time periods to meet the regulation. |
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
The project 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 included reference to the drug and alcohol treatment activities.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The audit shall be scheduled by the CEO within the next 45 days (1/22/2021) and the CEO shall be responsible to ensure the scheduled audit is completed. The audit will be made available to the department upon request. Ongoing, the CEO will be responsible to ensure the annual audit is completed after the close of each fiscal year. |
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
Based on a review of two of seventeen client records reviewed, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client #9 was admitted on April 14, 2020 and was a current client at the time of the inspection. On June 8, 2020, it was documented that there was communication between the facility and another treatment provider; however, a signed informed and voluntary consent form was not documented in the client ' s record.
Client #13 was admitted on September 29, 2020 and was a current client at the time of the inspection. There was no signed informed and voluntary consent form for the funding source documented in the client ' s record.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The Program Director will hold training on confidentiality and proper release formulation within the next 30 days (1/21/2021). The training will be mandatory for all clinical and intake staff. The training will cover the 5 domains of the 255.5 regulations, the 42 cfr proper release formulation. The training will review the need to indicate proper client and witness signatures, offering copies to clients, proper dates, and indicating the proper names of a person, agency or organization to which disclosure is to be made. Training certificates shall be kept in the HR binder of each employee to serve as proof of training. Post training, The Program director shall complete audits monthly on 10% of the charts to identify and issues with ROI's. If an issue is noted the clinical supervisor shall return the chart to the counselor for correction and it will be documented in a supervisor meeting. The audit process shall be ongoing. The program director shall resolve the ROI issue cited in client 13 by 1/21/2021. |
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
Based on the review of three of seventeen client records reviewed 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 name of the person, agency or organization to whom disclosure is made.
Client #6 was admitted on July 30, 2020 and was discharged September 9, 2020. A release of information form, signed and dated on September 10, 2020, did not document a name of person, agency or organization to whom disclosures were to be made to.
Client #12 was admitted on July 9, 2020 and as a current client at the time of the inspection. Two release of information forms, signed and dated on July 9, 2020, did not document a name of person, agency or organization to whom disclosures were to be made to.
Client #14 was admitted on November 3, 2020 and was a current client at the time of the inspection. A release of information form, signed and dated on November 3, 2020, did not document a name of person, agency or organization to whom disclosures were to be made to.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The Program Director will hold training on confidentiality and proper release formulation within the next 30 days (1/21/2021). The training will be mandatory for all clinical and intake staff. The training will cover the 5 domains of the 255.5 regulations, the 42 cfr proper release formulation. The training will review the need to indicate proper client and witness signatures, offering copies to clients, proper dates, and indicating the proper names of a person, agency or organization to which disclosure is to be made. Training certificates shall be kept in the HR binder of each employee to serve as proof of training. Post training, The Program director shall complete audits monthly on 10% of the charts to identify and issues with ROI's. If an issue is noted the clinical supervisor shall return the chart to the counselor for correction and it will be documented in a supervisor meeting. The audit process shall be ongoing. The program director shall resolve the ROI issue cited in client 6, 12 and 14 by 1/21/2021. |
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
Based on the review of three of seventeen client records the project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 for releases of information.
Client #2 was admitted on June 25, 2020 and was a current client at the time of the inspection. A release of information form to a county court official, signed and dated by the client on September 18, 2020, allowed for the release of the discharge summary and last dose, thus exceeding the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on June 2, 2020 and was discharged on October 15, 2020. A release of information form to a probation officer, signed and dated by the client on July 21, 2020, allowed for the release of prescribed medications, thus exceeding the limits established by 4 Pa. Code 255.5.
Client #12 was admitted on July 9, 2020 and was a current client at the time of the inspection. A release of information form to a probation officer, signed and dated by the client on September 9, 2020, allowed for the release of prescribed medications, thus exceeding the limits established by 4 Pa. Code 255.5.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
within the next 30 days (1/21/2021). The training will be mandatory for all clinical and intake staff. The training will cover the 5 domains of the 255.5 regulations, the 42 cfr proper release formulation. The training will review the need to indicate proper client and witness signatures, offering copies to clients, proper dates, and indicating the proper names of a person, agency or organization to which disclosure is to be made. Training certificates shall be kept in the HR binder of each employee to serve as proof of training. Post training, The Program director shall complete audits monthly on 10% of the charts to identify and issues with ROI's. If an issue is noted the clinical supervisor shall return the chart to the counselor for correction and it will be documented in a supervisor meeting. The audit process shall be ongoing. Additionally, client 2 and 7 will be asked to revoke the ROI referenced as exceeding the 255.5 regulations to prevent a future breach. Client 2 and 7 will also be asked to sign a new ROI to replace the revoked roi that meets the 255.5 regulations for disclosure. This step will be completed by the program director within 30 days (1/21/2021). |
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
The program failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
During the week of August 9, 2020 through August 15, 2020, the patient census was 302. The program was required to provide at least 30.2 physician hours. There were 18 physician hours documented.
During the week of August 30, 2020 through September 5, 2020, the patient census was 290. The program was required to provide at least 29.0 physician hours. There were 13 physician hours documented.
During the week of November 8, 2020 through November 14, 2020, the patient census was 288. The program was required to provide at least 28.8 physician hours. There were 18 physician hours documented.
This is a repeat citation from the inspections conducted on February 14, 2019 and January 23, 2020.
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 MD to have vacation coverage for the existing MD's and additional hours for patient services. The CEO of Soar will be responsible for the recruitment and hiring of an additional MD. The recruitment and hiring of a MD shall be ongoing
|
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.
|
Observations
Based on a review of seven of sixteen patient records the program failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years.
Patient #2 was admitted on June 25, 2020 and was a current patient at the time of the inspection. The patient was missing 1.5 of the 2.5 psychotherapy hours required for the months of September 2020 and October 2020 and .5 of the 2.5 psychotherapy hours required for the month of November 2020.
Patient #3 was admitted on September 17, 2019 and was a current patient at the time of the inspection. The patient was missing 2.5 of the 2.5 psychotherapy hours required for the month of October 2020 and 1.5 of the 2.5 psychotherapy hours required for the months of September 2020 and November 2020.
Patient #4 was admitted on September 29, 2019 and was a current patient at the time of the inspection. The patient was missing 2.5 of the 2.5 psychotherapy hours required for the month of October 2020 and 1.5 of the 2.5 psychotherapy hours required for the month of November 2020.
Patient #6 was admitted on July 30, 2020 and was discharged on September 9, 2020. The patient was missing .5 of the 2.5 psychotherapy hours required for the month of August 2020.
Patient #7 was admitted on June 2, 2020 and was discharged on October 15, 2020. The patient was missing 1.5 of the 2.5 psychotherapy hours required for the months of July 2020 and September 2020 and .5 of the 2.5 psychotherapy hours required for the month of August 2020.
Patient #11 was admitted on November 13, 2020 and was a current patient at the time of the inspection. The patient was missing 2.5 of the 2.5 psychotherapy hours required for the month of October 2020, 1.5 of the 2.5 psychotherapy hours required for the months of August 2020 and November 2020 and .5 of the 2.5 psychotherapy hours required for the months of July2020 and September 2020.
Patient #12 was admitted on July 9, 2020 and was a current patient at the time of the inspection. The patient was missing 2.5 of the 2.5 psychotherapy hours required for the month of November 2020.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
During COVID, Soar Corp will continue to utilize Telehealth as a measure to continue psychotherapy services for individual sessions. Group therapy sessions are not utilized during this period due to COVID restrictions. To document the inability to complete the therapy sessions due to COVID restrictions soar corp shall take the following steps. First the counselor shall place a non-billable note in the chart for each failed outreach call made for an agreed upon session time by phone. The counselors will place a non-billable note to chart reflecting any occurrences of a client changing, cancelling or ending a phone session early. On a monthly basis, the counselors shall place a monthly summery sheet in the chart to reflect significant gaps of service, non- compliance with treatment and any interventions implemented. The summery sheet will also reflect the number of and dates of missed therapy sessions. The program director shall be responsible for monitoring and compliance. The new system will be in effect within 30 days 1/21/2021 to allow notification of staff. Additionally, the program director will monitor the psychotherapy hours of the facility to ensure that a minimum 2.5 psychotherapy hours will be offered through individual counseling sessions, since group sessions are not being offered at this time.
|
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on the review of two applicable patient record reviewed the program failed to transfer patient files that included psychosocial summaries.
Patient #15 was admitted on June 21, 2018 and was transferred on June 29, 2020.
Patient #16 was admitted on September 24, 2014 and was transferred on October 13, 2020.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
The program Director shall complete an in-house training within the next 30 days (1/21/21) regarding patient transfers. The training shall review all items to be included within the transfer package,
Including the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and steps to obtain and document the written consent of the patient. Staff will be informed to meet the regulation, the entire transfer package must be sent even if the receiving provider requested not to receive a portion of the package. Additionally, the training will cover the need to document in writing that the agency notified a transferring narcotic treatment program of the admission of the transferred patient and the date of the agency gave the initial dose to the patient. Staff will be instructed to keep a copy of a fax confirmation sheet and attach it to the dose verification to serve as proof that a transferring narcotic treatment program was notified of the admission. Ongoing, the program director shall review a transfer package prior to being sent to ensure the documentation is complete and accurate.
|
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.
|
Observations
Based on the review of two applicable patient records the program failed to document in writing that it notified a transferring narcotic treatment program of the admission of the transferred patients and the date of the initial dose given.
Patient #9 was admitted on April 14, 2020 and was a current patient at the time of the inspection.
Patient #13 was admitted on September 29, 2020 and was a current patient at the time of the inspection.
This is a repeat citation from the inspection conducted on January 23, 2020 inspection.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
The program Director shall complete an in-house training within the next 30 days (1/21/21) regarding patient transfers. The training shall review all items to be included within the transfer package,
Including the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and steps to obtain and document the written consent of the patient. Staff will be informed to meet the regulation, the entire transfer package must be sent even if the receiving provider requested not to receive a portion of the package. Additionally, the training will cover the need to document in writing that the agency notified a transferring narcotic treatment program of the admission of the transferred patient and the date of the agency gave the initial dose to the patient. Staff will be instructed to keep a copy of a fax confirmation sheet and attach it to the dose verification to serve as proof that a transferring narcotic treatment program was notified of the admission. Ongoing, the program director shall audit all transfer admissions and discharges within 15 days to ensure the documentation is complete and accurate.
|
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
Based on the review six of seventeen client records reviewed the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client #1 was admitted on October 22, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan, completed on October 26, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the month of November 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the month of November 2020.
Client #3 was admitted on September 17, 2019 and was a current client at the time of the inspection. A treatment plan update, completed on February 17, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the month of October 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of September 2020, October 2020 and November 2020.
Client #4 was admitted on September 29, 2020 and was a current client at the time of the inspection. A preliminary treatment plan, completed on September 29, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the month of October 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of October 2020 and November.
Client #7 was admitted on June 2, 2020 and was discharged on October 15, 2020. A comprehensive treatment plan, completed on November 15, 2019, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received group counseling sessions for the months of June 2020, July 2020, August 2020, September 2020, October 2020 and November 2020.
Client #9 was admitted on April 14, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan, completed on May 14, 2020 indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for week of September 19, 2020 through September 13, 2020 and the month of November 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of April 2020, May 2020, June 2020, July 2020, August 2020, September 2020, October 2020 and November 2020.
Client #15 was admitted on June 21, 2018 and was discharged on June 29, 2020. A treatment plan update, completed on February 14, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of April 26, 2020 through May 2, 2020, May 3, 2020 through May 9, 2020 and May 10, 2020 through May 16, 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of April 2020, May 2020, June 2020, July 2020, August 2020, September 2020, October 2020 and November 2020.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
As of march of 2020, all patients have been excused from attending group therapy sessions as part of the emergency action plan for COVID that was submitted to DDAP. Individual sessions are being conducted by telehealth to make all attempts to provide counseling services according to the individual treatment plan. To document difficulties in meeting this domain soar shall take the following actions. First, the mention of group therapy sessions will be removed from all treatment plans as of 12/28/20 and shall not be referenced as an approved counseling session on the plans till the COVID restrictions are lifted. Second, to document any difficulties in completing individual therapy sessions, the counselor shall place a non-billable note in the chart for each failed outreach call sessions by phone. The counselors will place a non-billable note to chart reflecting any occurrences of a client changing, cancelling or ending a phone session early. On a monthly basis, the counselors shall place a monthly summery sheet in the chart to reflect significant gaps of service, non- compliance with treatment plans and being excused from counseling sessions. The summery sheet will also reflect the number and dates of missed therapy sessions. The regional Project Director shall issue an instructional Memo to all clinical staff of the facility within 30 days 1.21.21 to notify the staff of the new system that must be followed. Post notification, the program director shall be responsible for ensuring the monthly summery sheets and non-billable notes are placed in the charts by the counseling staff. |