INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on January 23, 2023 through January 24, 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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704.11(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 that all staff persons received at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee # 3 was hired as a counselor on February 15, 2021 and was due to have the TB/STD training no later than February 15, 2022. However, the TB/STD training was not completed until June 21, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/1/2023 a share drive document has been established to track the training requirements for staff. The regional director has shared the document with the program directors and clinical supervisors of the agency. Monthly during a supervision session, the supervisor shall review the required trainings with the staff member and assist with locating trainings as needed. Quarterly, the HR assistant will review the training grid and email each staff member to review their current training hours and outline required trainings to complete. The first email notification shall be sent within 30 days (3/6/23) and the program director shall monitor for completion. |
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 August 2022 and September 2022 fire drills conducted.
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 24, 2023 at approximately 1:30 PM, the facility failed to secure hard copy client records within locked storage containers.
There were unsecured hard copy client records located in the intake office, a doctor's office, and a counselor ' s office, all of which were 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) 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 one of seven client records reviewed.
Client # 2 was admitted on June 22, 2022 and was still active at the time of the inspection. There was evidence of disclosures to a medical provider on November 30, 2022, December 9, 2022, and December 30, 2022; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
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. |
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 # 5 was admitted on February 21, 2022 and was discharged on May 26, 2022. The release of information form to an emergency contact was signed and dated by the client on January 10, 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 21, 2022 annual licensing renewal inspection.
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. |
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 facility failed to ensure that narcotic treatment physician services were provided at least 1 hour per week onsite for every ten patients.
During the week of August 22, 2022 through August 28, 2022, the patient census was 166. This required 16.6 physician hours during the week; however, there were only 16 physician hours documented.
During the week of November 21, 2022 to November 27, 2022 the patient census was 162. This required 16.2 physician hours during the week; however, there were only 13.5 physician hours documented.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 1/2/23, the agency has secured additional hours of service from the Physician Assistant. As of result the current MD scheduled was restricted and the medical hours for Soar Levittown will be increased to a total 24 hours per week, where 18 hours will be completed by a MD and 8 hours will be completed by the Physician Assistant. As of 2/1/23, the ratio shall be monitored by the QI department to ensure compliance |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on an administrative review, the facility failed to ensure that time provided by the physician assistant or certified registered nurse practitioner did not exceed two-thirds of the required narcotic treatment physician time.
During the week of August 29, 2022 to September 4, 2022, the patient census was 166 requiring 16.6 narcotic treatment physician hours and no more than 11 of those hours were to be provided by a certified registered nurse practitioner. All the required narcotic physician time was provided by the certified registered nurse practitioner.
During the week of September 12, 2022 to September 18, 2022, the patient census was 156 requiring 15.6 narcotic treatment physician hours and no more than 10 of those hours were to be provided by a certified registered nurse practitioner. All the required narcotic physician time was provided by the certified registered nurse practitioner.
During the week of September 26, 2022 to October 2, 2022, the patient census was 160 requiring 16 narcotic treatment physician hours and no more than 10 of those hours were to be provided by a certified registered nurse practitioner. All the required narcotic physician time was provided by the certified registered nurse practitioner.
During the week of October 10, 2022 to October 16, 2022, the patient census was 158 requiring 15.8 narcotic treatment physician hours and no more than 10 of those hours were to be provided by a certified registered nurse practitioner. All the required narcotic physician time was provided by the certified registered nurse practitioner.
During the week of October 24, 2022 to October 30, 2022, the patient census was 162 requiring 16.2 narcotic treatment physician hours and no more than 11 of those hours were to be provided by a certified registered nurse practitioner. All the required narcotic physician time was provided by the certified registered nurse practitioner.
During the week of November 7, 2022 to November 13, 2022, the patient census was 163 requiring 16.3 narcotic treatment physician hours and no more than 11 of those hours were to be provided by a certified registered nurse practitioner. All the required narcotic physician time was provided by the certified registered nurse practitioner.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 1/2/23, the agency has secured additional hours of service from the Physician Assistant. As of result the current MD scheduled was restricted and the medical hours for Soar Levittown will be increased to a total 24 hours per week, where 18 hours will be completed by a MD and 8 hours will be completed by the Physician Assistant. As of 2/1/23, the ratio shall be monitored by the QI department to ensure compliance |
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 and document a random urinalysis at least monthly in two of seven patient records reviewed.
Patient # 2 was admitted on June 22, 2022 and was still active at the time of inspection. There was no documented drug screen urinalysis, in the record, for the month of September 2022.
Patient # 7 was admitted on January 30, 2019 and was discharged on November 15, 2022. There was no documented drug screen urinalysis, in the record, for the month of October 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 |
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
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month, 1 hour of which shall be individual psychotherapy, during each patient's first 2 years in treatment in two of six applicable patient records reviewed.
Patient # 1 was admitted on October 27, 2022 and was still active at the time of the inspection. The record of service and progress notes documented that during the month of November 2022, there were 2 hours of psychotherapy provided to the patient and during the month of December 2022, there was 0 hours of psychotherapy provided to the patient.
Patient # 2 was admitted on June 22, 2022 and was still active at the time of the inspection. The record of service and progress notes documented that during the months of September 2022, October 2022, and December 2022, there were 0 hours of psychotherapy provided to the patient each month and during the month of November 2022, there were 2 hours of psychotherapy provided to the patient.
This is a repeat citation from the January 21, 2022 and December 3, 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 1/2/2023, the site has ended all COVID restrictions and has return to mandating group and individual counseling services as outlined by agency policy. To ensure regular attendance is achieved the following process will be in effect as of 2/17/23. Every two weeks, the clinical supervisor will now run the "patients not counseled report" to identify patients who have not completed the required psychotherapy hour or hours as required by regulation. The clinical supervisor and / or counselor shall place the patient on hold for treatment completion. Continued non-compliance with, patient no shows for, or cancellations of scheduled treatment sessions shall be documented on a non-billable note by the primary counselor. The non-billable notes shall be kept in the patient's EMR and serve as proof that attempts for sessions were made by staff. The process will be monitored by the program director to ensure completion. |
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 and reviewed, dated, and signed by the medical director in one of four applicable patient records reviewed.
Patient # 5 was admitted on February 21, 2022 and was discharged on May 26, 2022. The annual evaluation of the patient's status was completed by the counselor on February 24, 2022; however, the evaluation was not reviewed, dated, and signed by the medical director.
This is a repeat citation from the January 21, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Director will send an instructional memo to all medical and clinical staff, outlining the appropriate process for completing a clinical annual evaluation. The memo will state the Medical Director must sign all clinical annual evaluations. The memo will be sent within 30 days (3/6/23). In an effort to ensure compliance, the QA department will audit clinical annual evaluations for completion, and appropriate signatures. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in two of three applicable client records reviewed.
Client # 4 was admitted on June 2, 2022 and was discharged on September 15, 2022. There was no follow-up information documented in the record at the time of the inspection.
Client # 7 was admitted on January 30, 2019 and was discharged on November 15, 2022. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/3/23, a new discharge follow up system has been created within the EMR system by the regional project director and the EMR vendor. The new d/c follow up system will eliminate the paper follow up forms, will require staff to document the follow up into the client's EMR record and shall provide an outstanding d/c follow up report. By 2/10/23, the regional project director shall send a memo by email to the program directors that states all discharge follow up will be completed electronically and to cease the use of paper follow ups. The memo will state that the program manager shall be responsible to run the audit report for incomplete follow up's every 2 weeks. Incomplete follow ups 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. |
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 to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was submitted and approved by the Department for the January 21, 2022 and December 3, 2020 annual licensing inspections. Failing to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment was again found to be a deficiency in the January 23, 2023 through January 24, 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 this processes to ensure completion |