INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection, conducted on December 29 - 30, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corporation Chester 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(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the facilities work schedule and copies of staff CPR and First Aid cards, the facility failed to ensure that CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills was onsite during the project's hours of operation.The findings include:Facility days of operation and hours: Monday - Friday 6 AM - 2:00 PM Saturday & Sunday 6 AM - 12:00 PMDispensing days and hours: Monday - Friday 6 AM - 12 PM Saturday & Sunday 6 AM - 11:00 AMBased on the work schedule and CPR and First Aid cards provided by the facility on December 29, 2015, the facility failed to provide CPR and First Aid coverage on Monday - Friday 12 PM - 2:00 PM and Saturday & Sunday from 11 AM until 2:00 PM. The facility has nursing staff on duty; however, they only work until 12 PM on Monday - Friday & they only work until 11 AM on Saturday & Sunday. The facility was unable to provide any additional documentation verifying that non-nursing staff would work beyond the dispensing hours. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/5/16, The Regional Director has located a outside trainer From Jefferson Health Systems to provide both CPR and First Aid training for all staff. The trainer has been contacted and all of the clinical and admin staff shall receive this training at the site within the next 60 days (3/15/16). Documentation of completion shall be kept in the employees HR binder and will be documented as a external training on the annual training log. To ensure this deficiency does not recur, SOAR'S current health and safety committee will include monitoring CPR and First Aid Certification into its inspections. Quarterly the committee will make a assessment of the shift needs for CPR and First Aid and place their recommendations for certification and training in Health and safety quarterly report. If training is indicated, the regional Director shall have the training scheduled for the stated shift. In addition, Soar shall have at least one Supervisor and two counselors on staff Monday - Friday 12 PM - 2:00 PM and Saturday & Sunday from 11 AM until 2:00 PM to ensure appropriate CPR and First Aid is available. This shall be a ongoing process to ensure compliance. |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of personnel records and a review of the Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that at least one-half of all training shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff in one of one record reviewed.The findings include:One personnel training file and the SRFSR were reviewed on December 29, 2015. The facility provided documentation showing that more than half of the facility's training's were provided in-house by facility staff. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The HR Director develop a excel training log grid listing all employees by 1/3/1/16. New hires shall be added to the sheet at the time of hire by the HR Director. Training hours completed shall be logged onto this sheet and also the employee annual training sheet. The training log will differentiate if the training is internal or external. HR Director and Regional Director shall audit quarterly the training hours to ensure the hours record in the HR file match the hour's record on the training grid. Additionally, on a monthly basis, the HR Director shall send a email to each individual counselor informing them of the documented training hours on file. This email will state the number of internal or external hours that need to be obtained in order to be in compliance. The e-mail notification shall be copied to the immediate supervisor of the counselor. The immediate supervisor shall discuss with the counselor their training hours, document the discussion and be responsible to ensure the training hours are met. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and a review of the Staffing Requirements Facility Summary Report form, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training.The findings include: One personnel record was reviewed on December 29, 2015, for documentation of at least 25 clock hours of annual training. The facility's training year reviewed was from January 1, 2014 through December 31, 2014.Employee # 5 was hired August 31, 2012, and was required to complete 25 hours of annual training. Employee # 5's training file included documentation of 21 training hours.In addition, the Staffing Requirements Facility Summary Report form which was finalized by the facility on December 29, 2015 documented less than 25 clock hours of training for employee # 5.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The HR Director develop a excel training log grid listing all employees by 1/3/1/16. New hires shall be added to the sheet at the time of hire by the HR Director. Training hours completed shall be logged onto this sheet and also the employee annual training sheet. The training log will differentiate if the training is internal or external. HR Director and Regional Director shall audit quarterly the training hours to ensure the hours record in the HR file match the hour's record on the training grid. Additionally, on a monthly basis, the HR Director shall send a email to each individual counselor informing them of the documented training hours on file. This email will state the number of internal or external hours that need to be obtained in order to be in compliance. The e-mail notification shall be copied to the immediate supervisor of the counselor. The immediate supervisor shall discuss with the counselor their training hours, document the discussion and be responsible to ensure the training hours are met. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the facility failed to obtain the services of independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The findings include:The facility's administrative documentation, specifically the financial audit, was reviewed on December 22, 2015. The document presented as the project's annual financial audit was titled, "Financial Statements." However, the document did not contain all the required elements of a financial audit, including the opinion of the accountant and the use of generally accepted accounting principles. The findings were reviewed with facility staff during the licensing inspection.This is a repeat deficiency. The facility was previously cited for non-compliance on November 22, 2013 and December 9, 2014.
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Plan of Correction
SOAR CORP'S Vice President of Operations shall retain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug and alcohol services. Soar shall have an official audit for 1/1/2014 to 12/31/2014 completed by the May 1, 2016. The Vice President shall have the audit firm supply more than the financial summary report that was issued for this inspection. SOAR CORP'S Vice President of Operations shall be responsible for ensuring the annual audit of financial activities is completed on an annual basis by the end of the second quarter (June), for the previous calendar year. SOAR CORP'S Vice President of Operations shall report the completion of this audit to the Soar Board who will act as a secondary check and balance to ensure completion. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant inspection, the facility failed to secure patient records within locked storage containers and maintain the confidentiality of patient identity and records.The findings include:A physical plant inspection was conducted on December 29, 2015. The facility's file room is located in the hallway/center of the facility. The facility failed to maintain the confidentiality of patient identity and records as the file room door was observed open and without a staff person at approximately 12:30 PM and approximately 1:15 PM. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 1/13/15, the Regional Director has issued an instruction memo to all of the staff of the Chester location regarding chart room procedure. The memo stated the following directives, first, the chart room must be closed and locked at all times and any staff who opens the chart room is responsible to close and lock it. Second, all chart must be returned to the chart room at the close of business to ensure confidentiality of records. Third, staff found to breach this procedure may result in progressive discipline action. The memo was sent from the regional director to all staff via e-mail to act as a verification of receipt of the memo The administrative and management staff shall monitor this daily to ensure the door stays closed to protect the records. Additionally an internal training on confidentiality shall be completed with all clinic staff by the regional director within the next 30 days (2/15/16). Documentation of this training shall be kept in the HR binder of the employee and shall be notes on the annual training log. The HR director shall monitor the completion of the training to ensure all staff has been in attendance of this training |