INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 1, 2020 through December 2, 2020 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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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
The project 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.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The audit shall be scheduled by the CEO within the next 60 days (2/11/2021) and the CEO shall be responsible to ensure the scheduled audit is completed. The audit will be made available to the department upon request. Ongoing, the CEO will be responsible to ensure the annual audit is completed after the close of each fiscal year. |
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
The program failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients. During the week of August 9, 2020 through August 15, 2020, the patient census was 180. The program was required to provide at least 18.0 physician hours. There were 16 physician hours documented. During the week of August 23, 2020 through August 29, 2020, the patient census was 183. The program was required to provide at least 18.3 physician hours. There were 16 physician hours documented. During the week of October 4, 2020 through October 10, 2020, the patient census was 195. The program was required to provide at least 19.5 physician hours. There were 16 physician hours documented. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Soar shall continue its effort to hire an additional full time MD to have vacation coverage for the existing MD's and additional hours for patient services. The CEO of Soar will be responsible for the recruitment and hiring of an additional MD. The recruitment and hiring of a MD shall be ongoing over the next 60 day (2/11/2021) |
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
The program failed to complete random urinalysis at least monthly in three of fourteen patient records reviewed.Patient #1 was admitted on January 21, 2020 and was discharged on June 17, 2020. A random urinalysis was not completed on this patient for the months of March 2020 and April 2020.Patient #4 was admitted on July 8, 2020 and was a current patient at the time of the inspection. A random urinalysis was not completed on this patient for the month of August 2020.Patient #9 was admitted on August 19, 2020 and was current patient at the time of the inspection. A random urinalysis was not completed on this patient for the month of November 2020.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
If available, the missing UDS screen for client 1, 4, and 9 shall be printed out from the lab site and placed back into the patient record by 12/30/2020. Moving forward, the regional project director will issue an instructional memo by 12/31/2020 UDS Screening. The memo will focus on establishing procedures to document client non-compliance with UDS screening. First, the nurses will now write a non-billable note to the client's chart on the date a Client refusal to complete a UDS screening. Additionally, if a UDS screening is postpone for any reason, the nurses will now write a non-billable note to the client's chart. Second, the nurses will now notify the program director by e-mail of the client's non- compliance with testing who will be responsible to address the behavior and document interventions used to address in a non-billable. The new system to document any non-compliance, refusal or postponement of testing will be in effect within 30 days 1/11/2021 to allow notification of staff. The Nursing manager will monitor the process to ensure completion |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The program failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, in ten of fourteen patient records reviewed.Patient #1 was admitted on January 21, 2020 and was discharged on June 17, 2020. The patient was missing .5 of the 2.5 psychotherapy hours required for the month of April 2020. The patient was missing 1.0 of the 2.5 psychotherapy hours required for the month of May 2020.Patient #2 was admitted on August 23, 2019 and was discharged on October 26, 2020. The patient was missing 2.5 of the 2.5 psychotherapy hours required for the months of August 2020, September 2020 and October 2020. Patient #4 was admitted on July 8, 2020 and was a current patient at the time of the inspection. The patient was missing 1.0 of the 2.5 psychotherapy hours required for the month of August 2020 and 2.5 of the 2.5 psychotherapy hours required for the month of September 2020.Patient #6 was admitted on August 30, 2019 and was a current patient at the time of the inspection. The patient was missing 1.0 of the 2.5 psychotherapy hours required for the month of October 2020 and 2.5 of the 2.5 psychotherapy hours required for the months of August and September 2020.Patient #9 was admitted on August 19, 2020 and was current patient at the time of the inspection. The patient was missing 2.5 of the 2.5 psychotherapy hours required for the month of November 2020. Additionally, the patient was missing 0.5 of the 2.5 psychotherapy hours required for the months of September 2020 and October 2020.Patient #10 was admitted on July 25, 2020 and was a current patient at the time of the inspection. The patient was missing 2.5 of the 2.5 psychotherapy hours required for the month of August 2020. Additionally, the patient was missing 0.5 of the 2.5 psychotherapy hours required for the months of October 2020 and November.Patient #11 was admitted on September 4, 2020 and was discharged on November 23, 2020. The patient was missing 1.5 of the 2.5 psychotherapy hours required for the month October 2020 and 0.5 of the 2.5 psychotherapy hours required for the month of November 2020. Patient #12 was admitted on June 12, 2020 and was discharged on October 16, 2020. The patient was missing 1.5 of the 2.5 psychotherapy hours required for the months of July 2020 and September 2020 and .5 of the 2.5 psychotherapy hours for the month of August 2020.Patient #13 was admitted on October 4, 2019 and was a current patient at the time of the inspection. The patient was missing 1.5 of the 2.5 psychotherapy hours required for the month of September 2020 and 1.0 of the 2.5 psychotherapy hours for the month of October 2020.Patient #14 was admitted on October 26, 2020 and was a current patient at the time of the inspection. The patient was missing 1.5 of the 2.5 psychotherapy hours required for the month of November 2020.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
During COVID, Soar Corp will continue to utilize Telehealth as a measure to continue psychotherapy services for individual sessions. Group therapy sessions are not utilized during this period due to COVID restrictions. To document the inability to complete the therapy sessions due to COVID restrictions soar corp shall take the following steps. First the counselor shall place a non-billable note in the chart for each failed outreach call made for an agreed upon session time by phone. The counselors will place a non-billable note to chart reflecting any occurrences of a client changing, cancelling or ending a phone session early. On a monthly basis, the counselors shall place a monthly summery sheet in the chart to reflect significant gaps of service, non- compliance with treatment and any interventions implemented. The summery sheet will also reflect the number of and dates of missed therapy sessions. The program director shall be responsible for monitoring and compliance. The new system will be in effect within 30 days 1/11/2021 to allow notification of staff |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The program failed to ensure that a patient in a narcotic treatment program for four or more years receive at least one hour of group or individual psychotherapy every two months in one applicable patient records reviewed. Patient #7 was admitted on June 27, 2016 and was a current patient at the time of the inspection. The patient received 1.0 hour of psychotherapy in the month of September 2020; however, there was no documentation that the patient received the 1.0 hour of psychotherapy required for the month of November 2020.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
During COVID, Soar Corp will continue to utilize Telehealth as a measure to continue psychotherapy services for individual sessions. Group therapy sessions are not utilized during this period due to COVID restrictions. To document the inability to complete the therapy sessions due to COVID restrictions soar corp shall take the following steps. First the counselor shall place a non-billable note in the chart for each failed outreach call made for an agreed upon session time by phone. The counselors will place a non-billable note to chart reflecting any occurrences of a client changing, cancelling or ending a phone session early. On a monthly basis, the counselors shall place a monthly summery sheet in the chart to reflect significant gaps of service, non- compliance with treatment and any interventions implemented. The summery sheet will also reflect the number and dates of missed therapy sessions. The program director shall be responsible for monitoring and compliance. The new system will be in effect within 30 days 1/11/2021 to allow notification of staff |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
The program failed to transfer patient files that included admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient and a written consent of the patient in one applicable patient record reviewed.Patient #2 was admitted on August 23, 2019 and was transferred on October 26, 2020. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The program Director shall complete an in-house training within the next 30 days (1/11/21) regarding patient transfers. The training shall review all items to be included within the transfer package,
Including the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and steps to obtain and document the written consent of the patient. Additionally, the training will cover the need to document in writing that the agency notified a transferring narcotic treatment program of the admission of the transferred patient and the date of the agency gave the initial dose to the patient. Staff will be instructed to keep a copy of a fax confirmation sheet and attach it to the dose verification to serve as proof that a transferring narcotic treatment program was notified of the admission. Ongoing, the program director shall audit all transfer packets admissions within 15 days to ensure completion
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The program failed to document in writing that it notified a transferring narcotic treatment program of the admission of the transferred patients and the date of the initial dose given to those patients in two applicable patient records reviewed.Patient #3 was admitted on October 19, 2020 and was a current patient at the time of the inspection.Patient #10 was admitted on July 25, 2020 and was a current patient at the time of the inspection. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The program Director shall complete an in-house training within the next 30 days (1/11/21) regarding patient transfers. The training shall review all items to be included within the transfer package,
Including the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and steps to obtain and document the written consent of the patient. Additionally, the training will cover the need to document in writing that the agency notified a transferring narcotic treatment program of the admission of the transferred patient and the date of the agency gave the initial dose to the patient. Staff will be instructed to keep a copy of a fax confirmation sheet and attach it to the dose verification to serve as proof that a transferring narcotic treatment program was notified of the admission. Ongoing, the program director shall audit all transfer packets admissions within 15 days to ensure completion
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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
The program failed to document an annual evaluation of each patient's status that was completed by the patient's counselor and reviewed, dated and signed by the medical director in one applicable patient record reviewed.Patient #7 was admitted on June 27, 2016 and was a current patient at the time of the inspection. An annual evaluation was completed on June 26, 2019 and the next annual evaluation was due no later than June 26, 2020; however, there was no annual evaluation documented in the patient record at the time of the inspection.These findings were reviewed with program staff during the licensing process.
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Plan of Correction
The missing annual evaluation noted for client 7 shall be completed by the program director and be placed in the client record within the next 2 weeks2/31/2020. By 1/21/21, 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 viewable to all counseling staff and supervisors, allowing staff to review and track daily. During supervision, the chart check grid shall be reviewed by the supervisor and plans to resolve outstanding work will be formulated and documented in a supervision note. The system will start to be used as of 1/21/21, and the clinical supervisor shall be responsible for the management of the system. |
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
The project failed to document an updated treatment and rehabilitation plan at least every 60 days in five of seventeen client records reviewed.Client #2 was admitted on August 23, 2019 and was discharged on October 26, 2020. A treatment plan update was completed on September 23, 2020 and the next update was due no later than November 23, 2020; however, there was no update documented in the record at the time of the inspection.Client #6 was admitted on August 30, 2019 and was a current client at the time of the inspection. A treatment plan update was completed on September 26, 2020 and the next update was due no later than November 26, 2020; however, there was no update documented in the record at the time of the inspection.Client #7 was admitted on June 27, 2016 and was a current client at the time of the inspection. A treatment plan update was completed on May 16, 2020 and the next update was due no later than July 16, 2020; however, there was no update documented in the record until September 13, 2020. Additionally, a treatment plan update was completed on September 13, 2020 and the next update was due no later than November 13, 2020; however, there was no update documented in the record at the time of the inspection.Client #8 was admitted on September 1, 2017 and was discharged on July 20, 2020. A treatment plan update was completed on January 24, 2020 and the next update was due no later than March 24, 2020; however, there was no update documented in the record at the time of the inspection.Client #12 was admitted on June 12, 2020 and was discharged on October 16, 2020. A comprehensive treatment plan was completed on July 31, 2020 and the next update was due no later than September 31, 2020; however, there was no update documented in the record at the time of the inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
By 1/21/21, 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 viewable to all counseling staff and supervisors, allowing staff to review and track daily. During supervision, the chart check grid shall be reviewed by the supervisor and plans to resolve outstanding work will be formulated and documented in a supervision note. The system will start to be used as of 1/21/21, and the clinical supervisor shall be responsible for the management of the system. |
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
The project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in nine of seventeen client records reviewed.Client #1 was admitted on January 21, 2020 and was discharged on June 17, 2020. A comprehensive treatment plan, completed on January 31, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of February 2, 2020 through February 8, 2020, February 9, 2020 through February 15, 2020, February 23, 2020 through February 29, 2020, March 8, 2020 through March 14, 2020, March 22, 2020 through March 28, 2020, March 29, 2020 through April 4, 2020, April 12, 2020 through April 18, 2020, April 26, 2020 through May 2, 2020 and May 17, 2020 through May 23, 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of April 2020 and May 2020.Client #2 was admitted on August 23, 2019 and was discharged on October 26, 2020. A treatment plan update, completed on March 23, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the months of August 2020, September 2020 and October 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of April 2020, May 2020, June 2020, July 2020, August 2020, September 2020 and October 2020.Client #4 was admitted on July 8, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan, completed on August 8, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of August 2, 2020 through August 8, 2020, August 16, 2020 through August 22, 2020, August 23, 2020 through August 29, 2020, October 4, 2020 through October 10, 2020 and no individual counseling session were documented for the month of September 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of July 2020, August 2020, September 2020 and October 2020.Client #5 was admitted on June 5, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan, completed on July 13, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of August 23, 2020 through August 29, 2020, August 30, 2020 through September 5, 2020 and September 6, 2020 through September 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of July 2020, August 2020, September 2020 and October 2020.Client #6 was admitted on August 30, 2019 and was a current client at the time of the inspection. A treatment plan update, completed on January 26, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the months of August 2020 and September 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of April 2020, May 2020, June 2020, July 2020, August 2020, September 2020 and October 2020.Client #7 was admitted on June 27, 2016 and was a current client at the time of the inspection. A treatment plan update, completed on January 14, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the months of October 2020 and November 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of April 2020, May 2020, June 2020, July 2020, August 2020, September 2020 and October 2020.Client #11 was admitted on September 4, 2020 and was discharged on November 23, 2020. A comprehensive treatment plan, completed on July 13, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of September 6, 2020 through September 12, 2020, September 20, 2020 through September 26, 2020, September 27, 2020 through October 3, 2020, October 4, 2020 through October 10, 2020, October 11, 2020 through October 17, 2020, October 18, 2020 through October 24, 2020 and November 1, 2020 through November 7, 2020. Additionally, there was no documentation in the record that the client received group counseling sessions for the months of September 2020, October 2020 and November 2020.Client #13 was admitted on October 4, 2019 and was a current client at the time of the inspection. A treatment plan update, completed on March 4, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received group counseling sessions for the months of April 2020, May 2020, June 2020, July 2020, August 2020, September 2020 and October 2020.Client #15 was admitted on March 27, 2020 and was a current client at the time of the inspection. A comprehensive treatment plan, completed on April 29, 2020, indicated that the client was to receive one individual counseling session and one group counseling session per week. There was no documentation in the records indicating that the client received individual counseling sessions for the weeks of July 5, 2020 through July 11, 2020, July 19, 2020 through July 29, 2020, July 26, 2020 through August 1, 2020 and August 9, 2020 through August 15, 2020. Additionally, there was no documentation in the records indicating that the client received group counseling sessions for the months of April 2020, May 2020, June 2020, July 2020, August 2020, September 2020 and October 2020.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
As of march of 2020, all patients have been excused from attending group therapy sessions as part of the emergency action plan for COVID that was submitted to DDAP. Individual sessions are being conducted by telehealth to make all attempts to provide counseling services according to the individual treatment plan. To document difficulties in meeting this domain soar shall take the following actions. First, the mention of group therapy sessions will be removed from all treatment plans as of 12/21/20 and shall not be referenced as service provided on the plans till the COVID restrictions are lifted. Second, to document any difficulties in completing individual therapy sessions, the counselor shall place a non-billable note in the chart for each failed outreach call sessions by phone. The counselors will place a non-billable note to chart reflecting any occurrences of a client changing, cancelling or ending a phone session early. On a monthly basis, the counselors shall place a monthly summery sheet in the chart to reflect significant gaps of service, non- compliance with treatment plans and being excused from counseling sessions. The summery sheet will also reflect the number and dates of missed therapy sessions. The regional Project Director shall issue an instructional Memo to all clinical staff of the facility within 30 days 1.11.21 to notify the staff of the new system that must be followed. Post notification, the program director shall be responsible for ensuring the monthly summery sheets and non-billable notes are placed in the charts by the counseling staff. |