INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6-7, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on review of personnel records conducted March 6-7, 2019, the facility failed to provide documentation of a qualifying degree for employee # 6. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As of 3/22/19, the employee cited in the report shall sign a new job description reflecting a assistant counselor status. As of this date the employee shall be supervised weekly under the assistant counselor status and shall have a professional development plan for the assistant counselor status. As part of the correction, the employee cited shall be required to complete a CAC / CADC application and certification. The employee referenced will have to submit the application within 6 months (9/18/19) and pull certification shall be required by 12/31/19. Moving forward, Soar Corp's Human Resource Director will require all new hires to provide a transcript along with degree verification at the time of hire as part of the hiring process. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on review of personnel records conducted March 6-7, 2019, the facility failed to provide documentation of a semi-annual performance evaluation for employee # 5.Employee # 5 was hired as a counselor assistant on May 7, 2018 and was still in that position at the time of the inspection. A semi-annual performance evaluation was due no later than November 7, 2018.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 employee cited complete a semi annual review with the program director by 4/1/19 and it will be placed in their HR chart. |
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 review of administrative paperwork during the onsite annual licensing inspection conducted on March 6-7, 2019. The facility failed to provide an annual audit obtained by an independent certified public accountant in accordance with generally accepted accounting principles.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Soar Corp's CEO will request that the Board of Directors approve an authorization for an audit to be completed for the Oct 1, 2017 to Sept 30th 2018 time period. The request for the audit shall be made at the next board meeting in 30 days. The CEO will be responsible in facilitating and arranging for an independent auditor within the next 90 days. Proof of completion shall be supplied as needed to the regional project director to meet the standard. Ongoing the CEO will make request for the approval of an auditor annually in the first quarter of each year and shall supply a copy to the Regional Project 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 a review of physician hours conducted on March 6-7, 2019, the facility failed to provide documentation of a narcotic treatment program providing narcotic treatment physician services at least 1 hour per week onsite for every ten patients. The week of October 28-November 3, 2018 with a client census of 114, the required physician hours are 11.4. The facility had 16 hours documented of which 0 were by the physician.The week of November 25-December 1, 2018 with a client census of 111, the required physician hours are 11.1. The facility had 16 hours documented of which 0 were by the physician.The week of December 23-December 29, 2018 with a client census of 113, the required physician hours are 11.3. The facility had 16 hours documented of which 0 were by the physician.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 holiday 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 |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of physician hours conducted March 6-7, 2019, the facility failed to document time provided by a physician assistant or certified registered nurse practitioner did not exceed two-thirds of the required narcotic treatment physician time.The week of October 28-November 2, 2018 of the 11.4 required hours, the CRNP documented 16 hours and the physician worked 0. The week of November 25- December 1, 2018 of the 11.3 required hours, the CRNP documented 16 hours and the physician worked 0. The week of November 25- December 23-29, 2018 of the 11.1 required hours, the CRNP documented 16 hours and the physician worked 0. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Soar used the CRNP with a Mid Level exception to provide dosing and administration decisions for a MD who was on vacation. To ensure the CRNP does not exceed two-thirds of the required narcotic treatment physician time, 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 |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on review of 7 patient records conducted on March 6-7, 2019, the facility failed to provide documentation within counselor notes of patient progress and status in patient record #3.Patient # 3 was admitted on July 27, 2018 and was still an active client at the time of the inspection. The last progress note documented was on February 4, 2019 and the last dosing was on February 10, 2019. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As of 3/18/19, The Regional Project Director has created a new form entitled "Excused Absence Notification". The form will document a excused absence from the program, Soar Corp's decision to keep the patient's file open and the expectation that the patient shall return to treatment at Soar Corp. The start and end date of the excused status along with the reason for / and location of the patient shall be indicated on the form. The form shall be completed by the medical or clinical staff during the notification of a patient absence and shall be filed within the client record in the case conference section of the chart. As of 3/18/19, an instructional memo and the form have been sent by e-mail to all management and nursing staff. the corporation shall start the use of this procedure and form as of 3/19/19 |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on review of patient records conducted March 6-7, 2019, the facility failed to provide documentation of treatment plan updates in 2 of 7 records reviewed. Patient # 3 was admitted on July 27, 2018 and was still an active client at the time of the inspection. A treatment plan update was completed on December 27, 2018 and the next update was due no later than February 27, 2018; however, there was no update documented in the record at the time of the inspection.Patient # 4 was admitted on January 29, 2018 and was still an active client at the time of the inspection. A treatment plan update was completed on December 4, 2018 and the next update was due no later than February 4, 2018; however, there was no update documented in the record 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
By 4/11/19, a excel data base chart check grid that highlights all due documentation within one week of the date will be developed program director and regional director. The excel data base will show and highlight all of the due dates for treatment plans, case conferences, and annuals. The excel data base will be stored within a network folder that is viewable to all counseling staff and supervisors, allowing staff to review and track daily. During the supervision sessions, the chart check grid shall be reviewed by the supervisor, approved completed treatment plans will be logged on the grid and due dates for treatment plans will be updated on the excel grid by the supervisor. . During the session, the Supervisor will establish a deadline for any outstanding work with the counselor. The supervisor will document the plan in the supervision note with the counselor. The system will start to be used as of 4/11/18, and will provide up to date tracking. The clinical supervisor shall be responsible for the management of the system of this system. Additionally, during periods of counselor transition, the clinical supervisor shall take the responsibility for managing the caseload and completing treatment plans on time with the patient during the transition period. |