INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 21-22, 2019 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:
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Plan of Correction
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records on February 21, 2019, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in records # 1 and 2.
Employee # 1 was hired for their current position on February 1, 2015 and was still in this position at the time of the inspection.
Employee # 2 was hired on April 29, 2014 and promoted to current position on December 30, 2018. The employee was still in this position at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Human Resource Director shall create an employee grid to track the due dates of all annual and semi-annual employee reviews within the next 30 days (4/15/19). HR Director will be responsible to check the employee grid on a weekly basis to identify upcoming employee reviews. The HR Director shall notify the Program Director and Site Supervisor by e-mail 2 weeks prior to the due date for the evaluation. The Program Director and Site Supervisor will complete the evaluation with the employee by the due date and submit it to the HR Director. The HR Director will then update the tracking date for the next review on the employee grid This will be an ongoing check and balance system to ensure time of completion. The two employee charts cited have been corrected and the reviews have been placed in their HR charts as of 3/15/19. |
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.
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Observations
Based on review of patient records on February 21-22, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 6, and 7.
Client # 1 was admitted on April 10, 2018 and was still an active patient at the time of the inspection. A consent to release form to a "PCP/MD" did not have witness signature.
Client # 6 was admitted on October 26, 2015 and was discharged on January 29, 2019. In the file there were signed consent to release forms without the name of the person, agency or organization to whom disclosure is to be made.
Client # 7 was admitted on June 2, 2015 and was still an active patient at the time of the inspection. In the file there were signed consent to release forms without the name of the person, agency or organization to whom disclosure is to be made.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director will hold a training on confidentiality and proper release formulation within the next 30 days (4/15/19). The training will be mandatory for all clinical and intake staff. The training will cover the 255.5 regulation, and release completion including proper signatures and properly indicating release forms with the name of the 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 and Clinical supervisor 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. As of 3/15/19 the three charts cited have been corrected by the Program Director |
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
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Observations
Based on review of physician hours on February 21-22, 2019, the facility failed to document physician services at least 1 hour per week onsite for every ten patients on the following dates:
*December 30, 2018-January 5, 2019 required 27.6 hours and had only 16 documented hours
*December 23-29, 2018 required 27.8 hours and had only 7 documented hours
*November 25-December 1, 2018 required 26.6 hours and had only 18 documented hours
*November 18-24, 2018 required 26.7 hours and had only 16 documented hours
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Soar Corp acknowledges a shortage of Physician hours during those weeks due to a Physicians scheduled vacation and time off. Effective Immediately, Soar will obtain coverage for all Physician planned vacations through a medical staffing agency that it currently has a relationship with. The arrangement of coverage with the medical staffing agency shall be completed by the Human Resource Director one week prior to the identified need. This plan for coverage is in effect immediately and is ongoing |