INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on January 26, 2022 through January 27, 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 a disclosure would 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 17, 2021 and was active at the time of inspection. A release of information form was signed and dated by the client on June 17, 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.
This is a repeat citation from the December 8, 2020 through December 10, 2020 annual licensing renewal inspection.
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). |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the facility failed to ensure that a narcotic treatment physician reviewed the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient's therapeutic dosage in one of five applicable records reviewed.
Patient #2 was transferred in and admitted on June 17, 2021 and was still active at the time of inspection. There was no documentation, in the record, of a dosage review occurring since being admitted to the program.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program Director shall offer an internal training to all of the clinical and intake staff on the topic of transferring patients in and out of the facility. The training will focus on the need to document in writing the notification of an initial dose and the last dose of a patient within the clinical chart. The training will be offered within the next 30 days (3/14/22). As of 2/1/22 Soar has hired 1 Quality Assurance staff member. Ongoing the QI staff will be responsible to audit all intakes and transfers within 1 week of the admission or discharge. Any missing notifications of an initial dose or the last dose will be reported to the program director who will be responsible for correction. The audit process will be going and in effect as of 3/14/2022. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient records reviewed.
Patient #2 was transferred in and admitted on June 17, 2021 and was still active at the time of inspection. There was no documentation, in the record, that the transferring narcotic treatment program was notified of the patient's date of admission and the date that the initial dose was given.
This is a repeat citation from the December 8, 2020 through December 10, 2020 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
the program Director shall offer an internal training to all of the clinical and intake staff on the topic of transferring patients in and out of the facility. The training will focus on the need to document in writing the notification of an initial dose and the last dose of a patient within the clinical chart. The training will be offered within the next 30 days (3/14/22). As of 2/1/22 Soar has hired 1 Quality Assurance staff member. Ongoing the QI staff will be responsible to audit all intakes and transfers within 1 week of the admission or discharge. Any missing notifications of an initial dose or the last dose will be reported to the program director who will be responsible for correction. The audit process will be going and in effect as of 3/14/2022. |
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 is to include an annual reevaluation by the narcotic treatment physician in two of five applicable records reviewed.
Patient #1 was admitted on April 16, 2019 and was active at the time of inspection. The last documented physical exam was performed on April 16, 2020.
Patient #4 was admitted on April 12, 2018 and was discharged on September 13, 2021. The last documented physical exam was performed on May 19, 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 1 will be completed by the program Physician as of 03/14/2022, patient 4 is discharged. 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(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 facility failed to document an annual evaluation of each patient's status completed by the patient's counselor and reviewed, signed, and dated by the medical director in one of five applicable records reviewed.
Patient #1 was admitted on April 16, 2019 and was active at the time of inspection. There was no documentation of an annual clinical evaluation for the year 2020 in the record.
This is a repeat citation from the December 8, 2020 through December 10, 2020 annual licensing renewal inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The missing annual evaluation noted for patient 1 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. |