INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the September 14, 2010 methadone monitoring inspection. The follow-up inspection was conducted on May 4, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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715.18(a)(1) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(1) HIV education services.
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Observations
Based on the review of patient records, administrative documentation and discussion with facility staff, the facility was unable to demonstrate how HIV education was provided to the patients enrolled in the facility for services.
The findings include:
Four patient records were reviewed May 4, 2011. Four patient records, # 1, 2, 3 and 4, contained a signed document stating they had received HIV education. However, the the plan of correction from the the monitoring survey dated September 14, 2010, stated a county agency would be contacted and a referral agreement reached. In addition, an inservice training was to be arranged as well. This was to have been completed by October 31, 2010. The program manager searched for documentation of the referral agreement, but there was none.
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Plan of Correction
Program Manager will contact local Delaware County agency either in Media or Chester to establish a referral agreement for testing and counseling for the HIV positive pts. Program Manager will monitor all referrals and make sure that referrals are up to date and current at all times. |
717.18(a)(2) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(2) Employment services.
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Observations
Based on a review of patient records, administrative documentation and a discussion with administrative staff, the facility failed to demonstrate provision of rehabilitative services that included employment services.
The findings include:
Four patient records were reviewed May 4, 2011. Four patient records, # 1, 2, 3 and 4, did not have documentation of referrals for employment services. However, the the plan of correction from the the monitoring survey dated September 14, 2010, stated local employment agencies would be contacted and a referral agreement established. This was to have been completed by October 31, 2010. The program manager searched for documentation of the referral agreement, but there was none.
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Plan of Correction
Program Manager will contact local employment services agency either in Media or Chester to set up a referral agreement. Program Manager will monitor all referrals to make sure that they are current and up to date at all times. |
715.18(a)(3) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(3) Adult educational services.
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Observations
Based on a review of patient records, administrative documentation and a discussion with administrative staff, the facility failed to demonstrate provision of rehabilitative services that included adult educational services.
The findings include:
Four patient records were reviewed May 4, 2011. Four patient records, # 1, 2, 3 and 4, did not have documentation of referrals for adult educational services. However, the the plan of correction from the the monitoring survey dated September 14, 2010, stated local agencies that provide adult education services would be contacted and a referral agreement established. This was to have been completed by October 31, 2010. The program manager searched for documentation of the referral agreement, but there was none.
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Plan of Correction
Program Manager will contact local agency to establish a new referral agreement contract. Program Manager will monitor all referral agreements to make sure that they are current and up to date at all times. |