INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 27-28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corporation Chester 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 and a plan of correction is due on January 29, 2011.
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Plan of Correction
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709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2009 annual report and an interview with the project director, the governing body failed to make available to the public an annual report which included a financial statement of income and expenses, as required by regulation.
The findings include:
The 2009 annual report was reviewed on December 27, 2010. The facility is publicly funded and required by regulation to make available to the public an annual report which includes a financial statement of income and expenses. On December 16, 2010, the facility made available to the public the 2009 annual report. The 2009 annual report did not include a financial statement of income and expenses.
On December 29, 2010 at approximately 10:15 PM the project director was interviewed. The project/facility director confirmed that a financial statement of income and expenses had not been included in the annual report.
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Plan of Correction
Project Director has already spoken to the Board and explained regulation in detail. Report for 2010 will include financial statement as required. Project Director will monitor for compliance. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of patient records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in three of sixteen client records.
The findings include:
Six patient records were reviewed on December 29, 2010 for informed and voluntary consents to release information from the patient prior to the disclosure of information. Five of the six records, #'s 1, 2, 4, 5, and 6 documented that urine drug screens had been sent out to a lab, but there was no documentation of a consent form signed by the patients prior to the lab work being sent out.
Patient #1 was admitted on 10-19-10. Urine drug screen reports had been completed by the lab on 10-28-10; 11-2-10; 11-12-10; 12-1-10, and 12-3-10. The record did not include a consent form allowing for the disclosure of information to the laboratory who conducted the analysis.
Patient #2 was admitted on 12-15-10. Urine drug screen reports had been completed by the lab on 11-17-10; 11-19-10; 12-8-10, and 12-10-10. The record did not include a consent form allowing for the disclosure of information to the laboratory who conducted the analysis.
Patient #4 was admitted on 11-2-10. Urine drug screen reports had been completed by the lab on 11-17-10 and 12-22-10. The record did not include a consent form allowing for the disclosure of information to the laboratory who conducted the analysis.
Patient #5 was admitted on 9-10-10. Urine drug screen reports had been completed by the lab on 10-14-10; 10-22-10; 10-25-10; 11-11-10; 12-6-10; and 12-16-10. The record did not include a consent form allowing for the disclosure of information to the laboratory who conducted the analysis.
Patient #6 was admitted on 10-19-10. Urine drug screen reports had been completed by the lab on 11-1-10; 11-3-10; 11-17-10, 12-4-10, 12-21-10, and 12-23-10. The record did not include a consent form allowing for the disclosure of information to the laboratory who conducted the analysis.
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Plan of Correction
Program Manager will do in-service training on proper way to do consents. Memo will also be given to all staff members detailing proper way and when to do consent forms. Program Manager will monitor for compliance through weekly supervision with clinical staff.Records in question at time of site visit will have releases in chart as soon as possible. |
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 fire drill logs and an interview with the facility director, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on December 29, 2010. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been set off from May 2010 through December 2010.
The facility director was interviewed on December 29, 2010. The facility director reported the facility could not set off a fire alarm or smoke detector due to sharing the suite with another agency. However the facility did not have an exemption that would allow an alternative means of alerting the occupants of a fire drill.
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Plan of Correction
Program Manager will request exception from DAPL in regards to not being able to set off the alarm system which is part of a larger building-wide system. Landlord will be asked to give SOAR copy of their testing for the city of Chester as required by code. Copy will be kept on file in Directors office. Project Director will monitor for compliance. Health and Safety Committee formed in Chester with 2 staff members given responsibility of all alarms and safety issues. Test forms will clearly indicate how drill was conducted. Monitored by Program Manager on monthly basis. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and the facility's policy and procedures manual, the facility failed to document a psychosocial evaluation that included the client's support system, preferred defense mechanisms, negative factors that could interfere with treatment, and the counselors' conclusions in five of six patient records reviewed.
The findings include:
Six patient records were reviewed on December 29, 2010. Six patient records required the completion of psychosocial evaluations. The facility's policy states a psychosocial evaluation to include the client's support system, preferred defense mechanisms, negative factors that could interfere with treatment, and the counselors' conclusions shall be completed within ten days of admission. Five patient records did not include a clinical assessment of the client; and only included non-evaluative, patient-reported historical information.
The facility failed to document a psychosocial evaluation that included a clinical assessment in patient records # 1, 2, 4, 5, and 6.
Patient # 1 was admitted on 10-19-2010. The psychosocial evaluation was completed on 10-25-10. The psychosocial evaluation did not include the client's preferred coping mechanisms and negative factors that could interfere with treatment.
Patient # 2 was admitted on 11-2-2010. The psychosocial evaluation was completed on 11-10-10. The psychosocial evaluation did not include the client's problems and needs, preferred coping mechanisms, negative factors that could interfere with treatment, and the counselors' conclusions/impressions.
Patient # 4 was admitted on 11-2-2010. The psychosocial evaluation was completed on 11-13-10. The psychosocial evaluation did not include the assets and strengths, supports systems and negative factors that could interfere with treatment.
Patient # 5 was admitted on 9-10-2010. The psychosocial evaluation was completed on 9-23-10. The psychosocial evaluation did not include the client's problems and needs, assets and strengths, supports systems, preferred coping mechanisms, negative factors that could interfere with treatment, and the counselors' conclusions/impressions.
Patient # 6 was admitted on 10-19-2010. The psychosocial evaluation was due to be completed by 10-29-10, as of the date of inspection there was no documentation of the psychosocial evaluation.
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Plan of Correction
Program Manager will perform an in-service training on proper way to do a psychsocial and the clinical assessment/evaluation. Program Manager will monitor for compliance during weekly supervision of clinical staff. |
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on the review of personnel records and an interview with the facility director and project director, the facility failed to ensure that the facility director met the qualifications prior to hire.
The findings include:
The Facility Director's personnel record was reviewed on December 29, 2010. The Facility Director did not meet the qualifications for the position.. The qualifications had not been met because employee #2 did not have a degree from an accredited institution. Employee # 2 is certified as an addictions counselor by the Commonwealth of Pennsylvania. The facility director and project director did confirm this.
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Plan of Correction
Project Director will request exception from DAPL for individual in question be allowed to keep position as Director based on years of experience in the field. Project Director will act as Program Director in interim period with person in-question now the Program Manager. Project director will continue in said role if exception not granted until another person can be hired as the Director. Project Director is responsible to correct and monitor this deficiency. |