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, 2023 through January 27, 2023 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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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 a review of personnel records, the facility failed to ensure that each counselor met the educational qualifications for the position in one of three applicable personnel records reviewed.
Employee # 9 was hired on June 9, 2022 and was still in the position at the time of the inspection. The employee had a bachelor's degree with the required experience; however, the major was in philosophy, which is not a qualifying major.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 2/17/2023, the employee referenced in the review shall sign a new job description and completed a new training plan for the position of assistant counselor from a full counselor. Supervision status will be moved to weekly to comply with regulations. The employee referenced will explore a CADC to meet standards. Moving forward, Human Resources will refer to DDAP list of approved degrees to verify the potential employee's degree as a qualifying degree for the position of counselor. A second verification shall be completed by the Regional Project Director prior to hire. The 2 step verification shall be ongoing. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, conducted on January 27, 2023 at approximately 1:00 PM, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.
In the administration building, the first-floor bathroom had a hot water temperature of 162.8 degrees Fahrenheit, and the second-floor bathroom had a hot water temperature of 152 degrees Fahrenheit at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program director has contacted the building owner regarding the water temperature. The hot water heater is scheduled to be adjusted no later than 2/10/23. Ongoing, Soar's maintenance staff shall take a reading quarterly to ensure compliance. The process will be ongoing |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's January 2022 through December 2022 fire drill logs, the facility failed to ensure that a fire alarm or smoke detector was set off during each fire drill.
There was no documentation that a fire alarm or a smoke detector was set off during the May 2022 fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 2/7/23, the regional project director will send an instructional memo to the staff of the facility by e-mail regarding the fire drill procedure. The memo instructs that during the fire drills an alarm or smoke detector must be set off. The memo states that the action of setting off the alarm shall be noted and indicated on the fire drill form. At the close of each month, the program director will be responsible to review the completed fire drill form to ensure it is complete and accurate. This process will start as of 2/17/23 and shall be ongoing. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection conducted on January 27, 2023 at approximately 1:00 PM, the facility failed to secure hard copy client records within locked storage containers.
There were unsecured hard copy client records located in a counselor's office on the second floor, which was unoccupied and unlocked at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 2/10/23, the regional project director shall send by email an instructional email to the staff of the program regarding the security of hard client charts. The memo will state that any hard copy client charts and charting material within a counselor's office must be return to the chart room by the close of business. The memo will also state that if a counselor leaves an office unoccupied for any moment they are instructed to lock the office door. To ensure compliance the program director shall check all offices at the close of business and return any charts found to the chart room. The program director shall address ongoing issues in this area during the supervision process. This process will start as of 2/17/23 and shall be ongoing. |
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 the disclosure is made on a consent to release information form in one of seven client records reviewed.
Client # 3 was admitted on May 25, 2022 and was still active at the time of the inspection. The release of information form to another treatment provider was signed and dated by the client on May 25, 2022; however, the form failed to include the name of the person, agency, or organization to whom the disclosure would be made.
This is a repeat citation from the January 27, 2022 and December 10, 2020 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/3 the regional project director and the EMR vendor have created a new audit report within the EMR system. The audit report number 142n entitled ROI's with missing company or individual names will identify any ROI in the system that fails to document the name of the person, agency, or organization to whom the disclosure is made to. As of 2/3/23, a directive has been sent by email to the clinical supervisors and program directors stating that rep142n must be completed ever two weeks. Incomplete releases noted on the report shall be corrected by the program director within 1 week. This process will start as of 2/17/23 and shall be ongoing. The QI department will monitor to ensure completion. The ROI referenced will be corrected by 2/24/23 by the counselor and patients |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of seven client records reviewed.
Client # 2 was admitted on September 29, 2022 and was still active at the time of the inspection.
The release of information form to another treatment provider was signed and dated by the client on October 6, 2022; however, the form did not include the purpose of the disclosure.
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 on the topic of releases and confidentiality by 3/6/2023. Proof of the training shall be placed in the employees HR file in the form of a certificate. The training will cover proper release formulation, the need to complete an informed and voluntary consent prior to the disclosure of information and the review of the 42CFR regulations. To ensure compliance the program director and qi staff shall audit a sample of charts monthly to ensure the procedure above is followed. The program director shall address ongoing issues in this area during the supervision process. This process will start as of 3/6/23 and shall be ongoing. The ROI referenced will be fixed by the client and counselor by 2/24/23 |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of seven client records reviewed.
Client # 5 was admitted on May 12, 2022 and was discharged on July 8, 2022. The release of information forms to outside laboratories were signed and dated by the witness on May 12, 2022; however, none of the forms included the dated signature of the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program director shall offer an internal training on the topic of releases and confidentiality by 3/6/2023. Proof of the training shall be placed in the employees HR file in the form of a certificate. The training will cover proper release formulation, the need to complete an informed and voluntary consent prior to the disclosure of information and the review of the 42CFR regulations. To ensure compliance the program director and qi staff shall audit a sample of charts monthly to ensure the procedure above is followed. The program director shall address ongoing issues in this area during the supervision process. This process will start as of 3/6/23 and shall be ongoing. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the narcotic treatment program failed to complete a random urinalysis at least monthly in one of seven patient records reviewed.
Client # 5 was admitted on May 12, 2022 and was discharged on July 8, 2022. There was no documented drug screen urinalysis, in the record, for the month of June 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 03/01/23, The Director of Nursing will run a "patient without a UDS report" from the EMR twice a month to identify the patients who have not completed the minimum urine drug screen requirements. Patients identified by this method shall be placed on hold to do so. Patients who refuse to complete a screening shall have a Non-billable note placed in their EMR record to document as such, and serve as proof that attempts for screening were made by staff. The process will be ongoing and will be monitored by the Director of Nursing to ensure completion. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form was submitted and approved by the Department for the January 27, 2022 and December 10, 2020 annual licensing inspections. Failing to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form was again found to be a deficiency in the January 26, 2023 through January 27, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within the next 60 days (4/6/2023) the CEO of the company shall interview and hire a Corporate Compliance Officer. The corporate compliance officer shall be responsible for overseeing the quality assurance and audit review process and for the completion of a plan of corrections from state and funding sources. The Corporate compliance officer shall provide a monthly report to the CEO and regional project director who will monitor the processes to ensure completion |