INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on January 10-11, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of administrative documentation and discussion with facility staff, the facility failed to develop an individual training plan for each of the nine employees reviewed.
The findings include:
Nine personnel records were reviewed January 8, 2013. Nine personnel were required to have an individual training plan. The administrative documentation reviewed included the policy and procedure manual and personnel records. Facility staff with whom discussions were held, included the project director, the facility director and the human resource facilitator.
The policy and procedure manual states the annual employee training plan would be completed in January of each year. All staff reviewed had a training plan dated January 3, 2013. However, the only training documented on all nine training plans were the pre-printed annually required training that everyone must take. There were no specific appropriate to the individual skill levels and needs of each employee.
Facility staff reported the training would be placed on the form after the training was actually taken by the employee making this more of a record of training and not a training plan for the year.
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Plan of Correction
Training plans will be completed by 1/31/2013. The training plans for each individual clinical and ancillary staff will be placed in the staff folder within the month of January (following SOAR CORP'S policy and procedure manual) of the New Year meeting the requirements of 704.11 Staff development. The preprinted trainings will be for funder and state requirements. The other information on the plan will identify the subject areas and potential resources for training which meet the requirements for the employee's position and which relate to the employees skill level and interest. The staff Managers and Supervisors will be responsible to collect this information from each employee and present it to the HR Director. The HR Director will be responsible to see this information is placed within the month of January of the New Year in the staff files. |
709.24(a)(1) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(1) Defined target population.
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Observations
Based on the review of administrative documentation and discussion with facility staff, the facility failed to include a defined target population as part of the coordination of treatment services to be provided.
The findings include:
The administrative documentation that included the policy and procedure manual was reviewed January 10, 2013. The target population portion of the written plan for client services was not updated for this site, but rather included the target population of the corporations original site.
The facility director confirmed it was not updated for this particular site.
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Plan of Correction
The Executive Director has completed a written statement reflecting the target population as part of the coordination services being provided. The written statement is specific to the Chester site of SOAR and was completed as of 1/17/13. The written statement for the SOAR Chester site was been added to the policy and procedure book as of 1/17/13 by the Executive Director. |
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 the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in eight of nine client records reviewed.
The findings included:
Eighteen client records were reviewed January 10-11, 2013. Nine client records were reviewed regarding release of information documentation. Eight client records, # 1, 2, 3, 4, 5, 7, 14 and 15, contained a consent to release information to the client's funding source that listed "concurrent reviews and/or authorization forms" as the information being released to the funding source. These items were not specific enough to define what actual information was to be released to the funding source, therefore allowing for the exceeding of 4 PA Code 255.5, which restricts the information to be released to very specific and limited areas.
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Plan of Correction
Effective 1/28/13 the executive director and the regional project director have completed the revision and update of the funding source released cited in the observation. The Release is now in effect as of 1/28/13. The modified and corrected release will be used at intake as of 1/28/13 and is now placed in the intake package for the intake worker to use. The updated ROI for this funding source has also been placed in the yearly clinical update package for ROI's and will be used by all counseling staff. Executive Director to monitor the use of the corrected ROI by completing monthly intake chart audits to ensure the correction is being used by staff. |
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, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in eight of ten client records.
The findings include:
Eighteen client records were reviewed January 10-11, 2013. A psychosocial evaluation was review in ten client records, #1, 2, 3, 4, 5, 6, 7, 14, 15 and 16.
The psychosocial evaluations in client records # 2, 3, 4, 5, 6, 7, 14 and 16 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 2, 3, 4, 5, 6, 7, 14 and 16 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 6, 7, 14 and 16 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 1, 2, 3, 4, 5, 6, 7, 14 and 16 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records # 2, 3, 4, 5, 6, 7, and 16 did not include an evaluation of the counselor conclusions/impressions of the client
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Plan of Correction
The executive Director will complete an update and expansion of the current psychosocial evaluation form within the next 30 days. This update and expansion will focus on adding larger spaces for comments for each target issue and the target issues for commenting will be expanded from 8 domains to 13 domains. The domains for comment will now include, coping skills, strengths, negative factors, clinical impressions, needs of a patient, current problems of a patient, supports, attitude, and preferences of a patient among others. Executive Director shall develop a handout on the proper completion of the psychosocial evaluation highlighting content and information that should be placed in each domain within the next 30 days and this will be given to all clinical counseling staff. Executive Director shall complete an in-service to all of the clinical counseling staff for the completion of the psychosocial evaluation. This in service will be completed within 30 days by the executive director. The executive Director shall monitor a counselor's follow through with the training by individual supervision and review of the psychosocial evaluations reviews submitted by a counselor prior to filing. Any submitted psychosocial evaluation that does not provide the required detail in the patient domains will be returned to the counselor by the executive director. The Counselor will be expected to submit a corrected psycho evaluation within 1 week of the document being returned for correction to the executive director. The Executive Director will submit all evaluations to filing after the content is approved. The process of content review will be ongoing with the Executive Director. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services on four of eight client records reviewed.
The findings include:
Eighteen client records were reviewed January 10-11, 2013. Eight client records were reviewed for documentation of proposed support services on the client's treatment plan. Client records # 1, 3, 5 and 14 had no documentation of proposed support services on the comprehensive treatment plan.
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Plan of Correction
Executive Director will complete a formal group training on the issue of treatment planning with all clinical staff including the counselors within the next 2 weeks (2/11/13). The executive director has already completed individual instruction on the lack of documentated support on a treatment plan with all 4 counselors of the facility as of 1/28/13. The counselors have received instructions on adding proposed sober support to the support mechanism box on the treatment plan during the supervison session with the executive director. Reinforcement of the need to document support will happen through the group training cited above by 2/11/13. The executive Director is currently monitoring a counselor's follow through with the instruction given through reviews of the treatment plan reviews being submitted. Any submitted treatment plan that does not provide any type of proposed sober support in the appropriate sections are being returned to the counselor by the executive director. The Counselor will be expected to submit a corrected plan within 1 week of the plan to the executive director for review. Continued review, returns and supervision of the process will be ongoing by the Executive Director. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to include an assessment of the client's progress in relationship to the stated goals in eight of nine client records reviewed.
The findings include:
Eighteen client records were reviewed January 10-11, 2013. Treatment plan updates to include an assessment of the client's progress in relationship to the stated goals were required in nine client records. The treatment plan updates included the documentation of new goals without explanation; goals were continued without any revision despite documentation that there was no progress and goals were dropped without any explanation, even when it was reported there had been no progress. The treatment plan updates were in client records # 1, 2, 3, 4, 5, 14, 15 and 16.
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Plan of Correction
Executive Director will complete a formal training on the issue of treatment planning with all clinical staff including the counselors within the next 2 weeks (2/11/13). Individual instruction with the facility's counselors has been completed as of 1/28/13 through suspervision. During the course of the training the progress on previous goals will be targeted and information on proper completion of this area will be provided by the executive director. The counselor will receive instructions on adding a revision, discontinued or continued statement while discussing the previous goals. The counselor will also receive instruction to add a statement in regards to the rational and purpose for any new goal stated. The counselor will also receive instruction on the need to modify objectives and action steps for all goals including times where no progress is stated. The executive Director shall monitor a counselor's follow through with the training by individual supervision and review of the treatment plan reviews submitted by a counselor prior to filing a plan to the chart. Any submitted treatment plan that does not provide the required detail in the progress on previous goals will be returned to the counselor by the executive director. The Counselor will be expected to submit a corrected plan within 1 week of the plan being returned to the executive director for review. |