INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 20, 2025 through November 21, 2025 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of two applicable personnel records reviewed. Employee # 7 was hired as a counselor on September 10, 2024 and moved to a counselor assistant on January 1, 2025. The employee was due to have the HIV/AIDS training and the TB/STD training no later than September 10, 2025; however, the HIV/AIDS training was not completed until September 26, 2025 and the TB/STD training was not completed until October 29, 2025.This is a repeat citation from the November 17, 2023 and November 21, 2024 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The trainings referenced continue to have limited approved offerings to meet the one year standard. The facility will utilize a HR training grid to track staff training requirements and has been posted this on electronic drive allowing all staff access to see their training needs. During scheduled supervision sessions, supervisors will now review required trainings with their staff, offering assistance in locating necessary courses as needed. Supervisors will document the outcomes of these discussions in the supervision notes. Additionally, the HR Assistant will conduct a monthly review of the training grid. Within 30 days of this notice (1/1/2026), the HR Assistant will send the first email to all staff, outlining their current training hours and required courses. The Program Director will monitor the employee's progress to ensure completion. |
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 an administrative review, the facility failed to 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.As of the date of the inspection, there was no financial audit completed for the project's fiscal year ending June 30, 2024.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within the next 90 days, Soar Corp will contract with an independent certified public accountant to perform an annual financial audit for the project's fiscal year ending June 30, 2024. The CEO of Soar is responsible for this process, with the immediate goal of securing a completed audit within the 90-day timeframe. The CEO will also ensure all future audits are completed within 90 days of their respective fiscal year-ends to maintain compliance with all relevant standards |
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 a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed. Client # 5 was admitted on June 12, 2025 and was discharged on October 2, 2025. There was evidence of a disclosure to another treatment provider on August 16, 2025; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure. Client #6 was admitted on January 24, 2019 and was discharged on June 11, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 1/25/2026, the Program Director will provide an internal training on releases and confidentiality. The training will cover proper release formulation, the need for informed and voluntary consent before disclosing information, and a review of 42 CFR regulations. It will also emphasize that specific names of emergency contacts and other individuals must be listed on a signed release of information (ROI). Additionally, the training will address the importance of obtaining consent before sharing transfer-in, transfer-out, and dosing information. Finally, the Program Director and the administrative assistant will conduct a monthly audit of a sample of charts to ensure this procedure is followed. The Program Director will address any ongoing issues during supervision sessions, and proof of the training will be placed in each employee's HR file in the form of a certificate. |
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 an administrative review, the narcotic treatment program failed to ensure narcotic treatment physician services were being provided at least 1 hour per week onsite for every ten patients during six of eighteen weeks reviewed. During the week of June 30, 2025 through July 6, 2025, the patient census was 211 and required 21.1 physician hours, but there were only 19 physician hours documented during the week.During the week of July 14, 2025 through July 20, 2025, the patient census was 212 and required 21.2 physician hours, but there were 16.5 physician hours documented during the week. During the week of July 28, 2025 through August 3, 2025, the patient census was 212 and required 21.2 physician hours, but there were 6.5 physician hours documented during the week. During the week of August 4, 2025 through August 10, 2025, the patient census was 209 and required 20.9 physician hours, but there were 15.5 physician hours documented during the week. During the week of August 11, 2025 through August 17, 2025, the patient census was 207 and required 20.7 physician hours, but there were 19 physician hours documented during the week. During the week of September 1, 2025 through September 7, 2025, the patient census was 209 and required 20.9 physician hours, but there were 15.5 physician hours documented during the week. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Soar is prioritizing the recruitment of an additional Telehealth Medical Doctor (MD) to immediately expand patient access and address care needs. The new Telehealth MD will assist to manage medication checks and extend overall physician coverage hours. This initiative is extend patient service hours, and ensure continuous clinical coverage, particularly during existing MD vacations. The CEO will personally lead the recruitment and hiring efforts, with the immediate goal of securing additional Telehealth MD hours within 90 days. Concurrently, the CEO will be responsible for establishing an ongoing process for monitoring the MD-to-patient census ratio to maintain continuous compliance with all relevant standards. |
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 ensure an annual evaluation of the patient's status was completed by the patient's counselor in one of four applicable patient records reviewed. Patient # 4 was admitted on March 10, 2020 and was discharged on August 6, 2025. The annual evaluation of the patient's status was last completed on March 18, 2024. The next annual evaluation of the patient's status was due to be completed by March 18, 2025; however, there was no documentation of an annual evaluation being completed prior to discharge.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Project Director issued an instructional memo on December 1st, 2025, via email to all Clinical Supervisors and Program Directors, mandating a new weekly audit procedure for clinical annuals. The EMR Audit Report 151e, titled "Annual Review /assessment by caseload," will be used weekly to identify all overdue or upcoming clinical annuals within a specified reporting period. The Clinical Supervisor is responsible for addressing all instances of missing or incomplete documentation with the assigned Counselor. The Counselor must complete and return the necessary corrections to the Clinical Supervisor within one week of receiving the notification. The process will be ongoing and start as of 1/1/2026 |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in five of seven applicable client records reviewed.Client # 1 was admitted on November 7, 2024 and was still active at the time of the inspection. Treatment plan updates, which were completed on February 7, 2025, April 21, 2025, May 2, 2025, July 1, 2025, September 2, 2025, and October 31, 2025, indicated the client was to receive one group counseling session per month. The record of services and progress notes indicated the client received no group counseling sessions from February 7, 2025 through the date of the inspection.Client # 3 was admitted on June 13, 2022 and was still active at the time of the inspection. Treatment plan updates, which were completed on January 9, 2025, March 6, 2025, June 19, 2025, August 12, 2025, and October 7, 2025, indicated the client was to receive one group counseling session per month. The record of services and progress notes indicated the client received no group counseling sessions from January 9, 2025 through the date of the inspection.Client # 4 was admitted on March 10, 2020 and was discharged on August 6, 2025. Treatment plan updates, which were completed on February 4, 2025, April 4, 2024, June 3, 2025, and July 31, 2025, indicated the client was to receive one group counseling session per month. The record of services and progress notes indicated the client received no group counseling sessions from February 4, 2025 through discharge. Client # 5 was admitted on June 12, 2025 and was discharged on October 2, 2025. Treatment plan updates, which were completed on June 25, 2025 and August 27, 2025, indicated the client was to receive one group counseling session per month. The record of services and progress notes indicated the client received no group counseling sessions from June 25, 2025 through discharge. Client # 7 was admitted on August 29, 2024 and was discharged on November 16, 2025. Treatment plan updates, which were completed on December 12, 2024, February 7, 2025, April 11, 2025, and April 16, 2025, indicated the client was to receive two group counseling sessions per month. The subsequent treatment plan updates, which were completed on June 13, 2025, August 13, 2025, and October 3, 2025, indicated the client was to receive one group counseling session per month. The record of services and progress notes indicated the client received no group counseling sessions from December 12, 2024 through discharge.This is a repeat citation from the November 17, 2023 and November 21, 2024 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Project Director issued a formal instructional memo via email to all Clinical Staff on November 25, 2025, mandating the following procedure for handling patient non-compliance with required treatment hours. The primary counselor is responsible for ensuring patients attend their mutually agreed-upon treatment requirements as documented in their individual treatment plans. The Program Director must run the "Patients Not Counseled Report" weekly to identify all instances of non-compliance with agreed-upon services. The Program Director will address the identified non-compliance issues directly with the assigned Counselor. Upon notification, the Counselor will place non-compliant patients hold until a meeting with the Counselor occurs. If the patient still fails to attend the required sessions after the intervention attempt, the Primary Counselor must document this in the patient's chart using a non-billable note. This note must clearly state that an attempt was made to provide services, but the patient refused. Program Directors are responsible for monitoring ensure this entire Plan of Correction (POC) is followed by all staff, beginning Jan 1, 2026. |
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 documentation and patient records, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for failing to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe was submitted and approved by the Department for the November 23, 2023 and November 21, 2024 annual licensing inspections. Failing to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe was again found to be a deficiency in the November 20, 2025 through November 21, 2025 annual licensing inspection.A plan of correction for failing to assure that counseling services were provided according to the individual treatment and rehabilitation plan was submitted and approved by the Department for the November 23, 2023 and November 21, 2024 annual licensing inspections. Failing to assure that counseling services were provided according to the individual treatment and rehabilitation plan was again found to be a deficiency in the November 20, 2025 through November 21, 2025 annual licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Project Director has formally recommended the creation and hiring of a Quality Improvement (QI) Manager role to the Board of Directors and the Corporate CEO. The QI Manager will complete Conducting continuous audits and follow-up activities related to all issued Plans of Correction (POCs) to ensure full compliance is achieved and sustained. The QI Manager will also ensure clinical staffing ratios and hours for Medical Doctor (MD) and Nursing staff are maintained according to regulatory standards. This compliance data shall be reviewed monthly. The approval and subsequent hiring by the CEO for the Quality Improvement Manager position is projected to be completed by March 1, 2026. |