INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on January 19, 2022 and January 21, 2022 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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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.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency or organization to whom the disclosure was to be made to on informed and voluntary consent to release information forms in one of seven client records reviewed.
Client #1 was admitted on June 10, 2021 and was active at the time of inspection. A release of information form was signed and dated by the client on June 10, 2021; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program director shall complete an internal training with all of the clinical staffing on the topic of proper release of information formulation. The training shall be completed within the next 30 days (3/14/22). The training will cover the types of information to be released, proper completion of the release to include the specific name of the person, agency, or organization to whom the disclosure was to be made and ensuring the release indicates the patient was offered a copy. Proof of training shall be kept in the HR binder to serve as proof. Post training, the quality assurance assist shall audit 10% of the electronic charts monthly to ensure releases are proper. The program director will be notified of releases needing to be corrected and shall be responsible to ensure completion. The QI review shall start within the next 30 days (3/14/22) and shall be ongoing. Client 1 noted will be asked by the primary clinician to complete an updated ROI within the next 30 days (3/14/22). |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of all informed and voluntary consent to release information forms were offered to the client in one of seven client records reviewed.
Client #4 was admitted April 11, 2019 and was discharged October 29, 2021. A release of information form, to another treatment provider, was signed and dated by the client on October 20, 2021; however, there was no documentation that a copy of the consent form was offered to the client.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The program director shall complete an internal training with all of the clinical staffing on the topic of proper release of information formulation. The training shall be completed within the next 30 days (3/14/22). The training will cover the types of information to be released, proper completion of the release to include the specific name of the person, agency, or organization to whom the disclosure was to be made and ensuring the release indicates the patient was offered a copy. Proof of training shall be kept in the HR binder to serve as proof. Post training, the quality assurance assist shall audit 10% of the electronic charts monthly to ensure releases are proper. The program director will be notified of releases needing to be corrected and shall be responsible to ensure completion. The QI review shall start within the next 30 days (3/14/22) and 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.
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Observations
Based on a review of patient records, the facility failed to document that each patient received at least 2.5 hours of psychotherapy group or individual sessions per month during the patient's first two years in treatment in two of five applicable records reviewed.
Patient #2 was admitted on January 18, 2021 and was active at the time of inspection. The patient record documented that the patient received 2 hours of psychotherapy for June 2021 and 1 hour of psychotherapy for October 2021.
Patient #7 was admitted on September 11, 2020 and was discharged November 29, 2021. The patient record documented that the patient received 0 hours of psychotherapy for each of the months of August, September, October, and November 2021.
This is a repeat citation from the December 20, 2020 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director shall issue a written instructional memo by 2/28/2022 regarding missed patient sessions. The instructional memo will be sent by email to verify completion. The instructional memo shall state that the counseling staff must indicate in a non-billable note any patient cancellations and or no shows. Counselors will be instructed to place a non-billable note in record reflecting any occurrences of a client changing, cancelling or ending a session early. Moving forward, on a weekly basis, Director also will run the "Not Counseled" report in the EMR Database to identify what patient missed their sessions. The Program Director will review EMR record to verify the non-billable note is entered and occurrence of missing notes shall be addressed in supervision with the counselor. The program shall be responsible for ongoing monitoring and compliance. The new system will be in effect within 30 days 2/28/2022. |
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 document the results of an annual physical examination given by the narcotic treatment program, which includes an annual reevaluation by the narcotic treatment physician in two of five applicable records reviewed.
Patient #2 was admitted on January 18, 2021 and was active at the time of inspection. The last documented physical exam was the initial physical exam performed on January 18, 2021.
Patient #7 was admitted on September 11, 2020 and was discharged November 29, 2021. The last documented physical exam was the initial physical exam performed on September 11, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The missing annual physical noted for patient 2 was completed by the program Physician as of 02/01/2022. Moving forward, the initial and annual physical shall be built into the EMR system (tower systems) and shall be completed by the attending MD in the EMR. The EMR system will have a built-in tracking system to identify Physicals that are coming due. The Tracking system shall be viewed weekly and patients identified as having a physical due within 2 weeks shall be placed for review. The Regional Project Director shall be responsible to have the new tracking system and the Physicals in the EMR. The new system shall be operational and in use within the next 60 days |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records, the facility failed to ensure a complete patient file, which is to include follow-up information, in one of four applicable records reviewed.
Patient # 5 was admitted February 15, 2019 and was discharged December 2, 2021. There was no documentation of post-discharge follow-up information in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The missing 30 day follow up letter for patient #5 has been completed as of 02/02/2022. Moving forward, the Program Director will complete biweekly chart audits to ensure that all documentation for discharged individuals are completed accurately and timely. Director will inform primary counselor of missing documentation and will discuss what actions need to be made in supervision. Moving forward., the Quality Assurance department will assist with auditing 10% of the electronic charts monthly to ensure complete documentation. The Program Director shall be responsible for ongoing monitoring and compliance. The new system will start within 30 days |
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 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 one of five applicable patient records reviewed.
Patient #7 was admitted on September 11, 2020 and was discharged November 29, 2021. There was no documentation of an annual clinical evaluation in the record prior to discharge.
This is a repeat citation from the December 11, 2020 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The missing annual evaluation noted for patient 7 shall be completed by the program director and be placed in the client record within the next 2 weeks, 2/28/2022. Moving forward, the 30 day Biopsychosocial and annual evaluation shall be built into the EMR system (tower systems) and shall be completed by the primary counselor in the EMR. The EMR system will have a built-in tracking system to identify Evaluations that are coming due. The Tracking system shall be viewed weekly and patients identified as having a evaluation due within 2 weeks shall be placed for review. The Program Director shall be responsible to have the new tracking system and the evaluations in the EMR. The new system shall be operational and in use within the next 60 days. |