INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 31, 2026 through September 1, 2026 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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709.25 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.
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Observations
Based on an administrative review, the facility 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 include reference to the drug and alcohol treatment activities.At the time of the inspection, there was no financial audit completed for the project's fiscal years ending June 30, 2024 and June 30, 2025.This is a repeat citation from the August 12, 2025 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO is responsible for overseeing the project's financial audit for the fiscal year ending June 30, 2025, and shall obtain Board approval and execute a contract with an external accounting firm within 30 days. The Board President and the CEO shall jointly oversee the audit process, ensuring all required materials are submitted to the external CPA and securing final delivery of the completed audit within 90 days (by December 14, 2026). On an ongoing basis, the Board President and the CEO are responsible for ensuring all subsequent audits are completed and submitted to the Regional Director and regulatory bodies as requested. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in four of seven client records reviewed.Client # 2 was admitted on June 24, 2025 and was discharged on May 26, 2026. A treatment plan update was completed on March 19, 2026 and the next update was due no later than May 19, 2026; however, the update was not completed prior to discharge. Client # 3 was admitted on December 26, 2023 and was discharged on September 22, 2025. A treatment plan update was completed on July 15, 2025 and the next update was due no later than September 15, 2025; however, the update was not completed prior to discharge. Client # 6 was admitted on May 1, 2025 and was active at the time of the inspection. A treatment plan update was completed on February 5, 2026 and the next update was due no later than April 5, 2026; however, the update was completed on June 23, 2026. Client # 7 was admitted on June 19, 2020 and was active at the time of inspection. A treatment plan update was completed on November 20, 2025 and the next update was due no later than January 20, 2026; however, the update was completed on January 27, 2026. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director shall conduct training for new clinical staff on treatment plan requirements by October 1, 2026. The training will focus on compliance timeframes, specifically requiring treatment plans to be completed two weeks prior to their expiration date to ensure all necessary signatures are secured before expiration. Effective October 1, 2026, the Program Director will generate weekly Audit Report #147D ("Treatment Plans Due in Date Range") and review it with clinical staff. Assigned staff are required to close out all identified treatment plans by the close of each week. The Program Director will oversee ongoing monitoring of weekly due dates, and any instances of missing or incomplete documentation will be addressed by the counselor's assigned Clinical Supervisor. |
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.
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Observations
Based on a review of client records, the facility failed to assure counseling services were being provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.Client # 1 was admitted on January 30, 2025 and was discharged on June 29, 2026. A treatment plan update, completed on February 13, 2026, indicated the client was to receive one individual therapy session per month. The record of service and progress notes indicated the client did not receive any therapy sessions during the month of March 2026. Client # 2 was admitted on June 24, 2025 and was discharged on May 26, 2026. A treatment plan update, completed on January 15, 2026, indicated the client was to receive one individual therapy session per month. The record of service and progress notes indicated the client did not receive any therapy sessions during the month of March 2026. Client # 6 was admitted on May 1, 2025 and was active at the time of inspection. A treatment plan update, completed on February 5, 2026, indicated the client was to receive one individual therapy session per month. The record of service and progress notes indicated the client did not receive any therapy sessions during the month of March 2026.This is a repeat citation from the August 12, 2025 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director shall conduct a training for all facility clinical staff on treatment and rehabilitation services by October 23, 2026. This training will focus on methods to ensure counseling services align with individual treatment and rehabilitation plans, as well as proper documentation procedures for treatment non-compliance. Effective October 23, 2026, following the completion of the training, the Program Director will run a weekly "Patient Not Counseled" report to identify patients with missed therapy sessions. The Clinical Supervisor will cross-check the system to ensure corresponding non-billable notes are entered. Any instances of missing documentation shall be addressed by the supervisor, who will require the counselor to complete the necessary correction |