INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23-24, 2018 by staff from the Division of Drug and Alcohol Program Licensure, for the approval to use Methadone in the treatment of narcotic addiction. 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Staffing Requirements Facility Summary Reports for all facilities of the project were reviewed for the licensing renewal inspection conducted at this specific facility on January 23-24, 2018. Based on this review, the project failed to employ one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors or counselor assistants employed with the project. The Staffing Requirements Facility Summary Reports submitted for the three facilities within the project identify three employees in the clinical supervisor position. The total number of hours per week provided to the project, by the counselors and counselor assistants, equates to 32 FTE counselor or counselor assistant positions within the project. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An additional clinical supervisor was hired and started working for Soar Corp on 1/10/18 at the Northeast Site to replace the previous clinical supervisor that was on leave. Qualifications were reviewed on site for this individual. The Regional Project Director and Human Resource Director shall continue to ensure the 8 to 1 ratios for supervisors are maintained to ensure compliance with the regulation |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
One personnel record was reviewed for the counselor assistant position on January 23, 2018. The facility failed to fully document the required close supervision and direct observation for employee record # 7. Employee # 7 was hired as a Bachelor's level counselor assistant on 7/25/17. The employee required close supervision for the first 6 months, which was to include at least 1 hour of direct observation per week. Weekly supervision notes were reviewed for the period of 7/25/17 - 1/23/18. Supervision notes were not documented for the following weeks: -Week of 8/20/17-Week of 9/3/17-Week of 10/15/17-Week of 10/22/17-Week of 11/5/17-Week of 11/19/17-Week of 12/3/17-Week of 12/31/17-Week of 1/14/18 In addition, the facility failed to properly demonstrate that weekly close supervision included at least 1 hour of direct observation once a week. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Regional Project Director shall complete an internal training with all of the clinical supervisors of the agency within the next 30 days. A copy of the current supervision policy outlining the assistant counselor documentation has been sent to all supervisors as of 3/16/18. The training shall focus on the supervision policy within the agency and the documentation process. the training shall discuss the need to complete weekly supervision sessions for all assistant counselors, the need to provide direct observation to all assistant counselors weekly. The training will focus on the methods to use for direct observation and how to document this into the supervision note to serve as verification and proof. The training will also focus on methods to document any missed supervision sessions due to vacations. Post training the regional director shall review the supervision notes quarterly to check for training compliance. Any revisions or errors shall be discussed with the clinical supervisor with the regional director |
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
Fire drill logs were reviewed for the licensing renewal inspection conducted on January 23-24, 2018. Fire drill documentation was reviewed for the period of February 2017 - December 2017. This documentation indicated that the facility failed to activate a fire alarm or smoke detector during each fire drill conducted within the reviewed time period. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective as of 4/1/18, Soar Levittown will have the ability to set off the alarm system in a test mode for all drills. The program Director will have written instructions on how to place the fire system in a test mode during drills and key staff that will be facilitating the drills shall be orientated to the test mode function within the next 2 weeks. As of 4/1/18 all fire drills will be completed in a test mode to allow the fire alarm to be set off without sending a trouble alarm. The alarm being set off shall be indicated on the fire drill form and the program director shall monitor in order to ensure compliance |
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
Administrative records were reviewed for documentation of an annual fiscal audit during the facility's licensing renewal inspection, conducted on January 23-24, 2018. The facility's fiscal year runs from October 1 to September 30. The document presented as the project's annual financial audit, for the fiscal year ending on September 30, 2016, was titled "Financial Statements." However, this document did not contain the opinion of the accountant, and included a statement indicating that an audit was not conducted. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Soar Corp's CEO will request that the Board of Directors approve an authorization for an audit to be completed for the Oct 1, 2016 to Sept 30th 2017 time period. The request for the audit shall be made at the next board meeting in 60 days. The CEO will be responsible in facilitating and arranging for an independent auditor within the next 90 days. Proof of completion shall be supplied as needed to the regional project director to meet the standard. Ongoing the CEO will make request for the approval of an auditor annually in the first quarter of each year |
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
Five client records were reviewed on January 23-24, 2018. The facility failed to obtain an informed and voluntary consent where consent was applicable for client record # 2. Client # 2 was admitted into treatment on 11/24/17 and was still active in treatment. A consent to release information to the client's treatment funding source was not documented in the client's record. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The ROI for the patient referenced in the report has already been signed and placed in the patient record. To prevent a future occurrence of a missing release of information from intake the program director will start to complete a full chart audit within the first 2 weeks of admission for all new intakes to the site. The audit will look for all required documentation from intake including funding Source releases. Copies of the completed audits shall be kept in a binder with the program director to be proof of this step being taken. Any error or missing documentation found in this step shall be corrected by the intake counselor within 1 week. The program director shall monitor the correction process. Currently, the patient ( client #2) has signed a active release for the funding source cited. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Five client records were reviewed on January 23-24, 2018. The facility failed to maintain documentation of a completed informed, voluntary, written consent for the administration of Methadone for client record # 3. Client # 3 transferred to this facility, from another facility of the same project, on 7/28/17, and was still active in treatment. The client received their initial dose of Methadone at this facility on 8/1/17. Documentation of a completed informed, voluntary, written consent for the administration of Methadone was not found in the client's record. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director of Soar Levittown shall have the patient in question sign the voluntary consent to treatment with methadone by 3/30/18. Moving forward, To improve the transfer process from another facility within the project Soar shall take the following steps. First, prior to a patient being transferred to a new location, the clinical supervisor at the transferring facility shall complete a full chart audit to ensure all required documentation has been completed and is present in the chart prior to the transfer. Any missing documentation identified at this point shall be corrected by the clinical supervisor prior to transferring the patient. On the date of transfer, the receiving facility of the in house transfer shall complete a chart audit on the received chart. The clinical Supervisor from the receiving program shall be responsible to complete this audit. If there is any missing documentation the previous clinical supervisor and the regional director shall be notified by e-mail. Once the previous supervisor is notified they will have 1 week to give the correction |
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
Five client records were reviewed on January 23-24, 2018. The facility failed to document the provision of a random urinalysis at least monthly for client record # 4. Client record # 4 was admitted into treatment on 2/17/17 and was discharged on 12/6/17. Documentation of a random urinalysis completed in the month of July 2017 was not found in the client's record. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Charge Nurse shall send out an instruction memo within 2 weeks to the nursing department staff by e-mail to serve as verification of notification and receipt. The memo shall state the need to document the attempt to collect a urine screen sample, the patient's refusal to provide a sample and the patient's choice to leave the facility without providing the sample. The memo will state the need of the nurse by the end of their shift to inform the charge nurse by e-mail of a patient's election to not provide a sample. Within 24 hours of receiving the e-mail the charge shall verify a nursing note exist to document the attempts to obtain a provision of urinalysis. this will be a ongoing process. the charge nurse shall address no-conformance with the procedure as needed |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Five client records were reviewed on January 23-24, 2018. For client record # 2, the facility failed to document that the facility has made all other efforts to retain the client prior to initiating an involuntary termination for non-payment of treatment fees. Client # 2 was admitted into treatment on 11/24/17, and was still active in treatment. Medical documentation in the client's record indicated that the client was put on a 21-day administrative detox schedule for non-payment of fees, to begin on 1/14/18. The client's standard Methadone dose was 55 mg. The client received a dose of 55 mg on 1/11/18, and then no-showed for dosing on 1/12/13 and 1/13/18. The client returned for dosing on 1/14/18, and received a decreased dose of 53 mg, as per the administrative detox schedule. A physician order dated 1/15/18 canceled the administrative detox, and also ordered for the client's dose to be increased to 60 mg. The client then received an increased dose of 60 mg on 1/15/18. Documentation in the client's record failed to demonstrate that the facility employed all other efforts to retain the client prior to initiating an involuntary termination. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The regional Project Director and the Program Director shall complete an in-service training with all clinical staff on the discharge process and types of acceptable discharges which can be completed. The training shall focus on the inability to discharge a patient due to finical reasons. The training will discuss treatment non-compliance being an acceptable reason for a discharge and that the treatment non-compliance needs to be documented by the means of treatment plan goals, and contracts prior to proceeding with a discharge. Proof of training shall be kept in the HR binder of the employee. Post training, all discharges shall be reviewed by a clinical supervisor prior to being presented to the MD for finalization. If it is found that documentation is not present to support the discharge, the request will be denied and reviewed with the requesting counselor. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Five client records were reviewed on January 23-24, 2018. For client record # 2, the facility failed to properly demonstrate that the client was given a fair review of their grievance by the narcotic treatment program director. Client # 2 was readmitted into treatment at the facility on 11/24/17 and was still active in treatment. The client was previously in treatment at the facility, admitted on 11/25/16 and then involuntarily terminated on 8/1/17. For the client's previous treatment episode, documentation in the client's record indicated that the client received written notification of involuntary termination on 7/17/17. The termination notice indicated that the client would be placed on an administrative detox schedule, effective 7/18/17 - 7/24/17. Based on a review of the facility's grievance records, the client filed a grievance against the termination on 7/20/17, and the facility director received the grievance on 7/24/17. A progress note dated 7/25/17 indicated that the clinical supervisor informed the client that the administrative detox would continue. Documentation in the client's record failed to demonstrate that the facility director conducted a fair review of the client's grievance prior to the client's involuntary termination. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To document that a fair hearing was completed Soar shall take the following steps. The grievance shall continue to be heard by the program director. A patients failure to show for a hearing shall be documented by the program director. After the grievance is heard or a patient fails to show for the hearing, the program director shall issue a written letter to the patient, cc a copy of the written letter to the patient's chart and attach a copy of the letter stating the decision to the grievance which was filed. This letter will serve as proof that the program director responded, heard and made the decision to uphold or reverse a decision to administrative discharge a patient. This documentation process is in effect immediately. Staff is informed by means of e-mail notification with instruction |
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
Five client records were reviewed on January 23-24, 2018. The project failed to document an annual evaluation completed by a counselor for client record # 3. Client # 3 transferred to this facility, from another facility of the same project, on 7/28/17, and was still active in treatment. The client was initially admitted to a narcotic treatment program with the project on 4/7/10. The most recent annual evaluation documented in the client's record was completed on 4/7/16. A subsequent annual evaluation was due to be completed by 4/7/17, and one was not found in the client's record. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To improve the transfer process from another facility within the project Soar shall take the following steps. First, prior to a patient being transferred to a new location, the clinical supervisor at the transferring facility shall complete a full chart audit to ensure all required documentation has been completed and is present in the chart prior to the transfer. Any missing documentation identified at this point shall be corrected by the clinical supervisor prior to transferring the patient. On the date of transfer, the receiving facility of the in house transfer shall complete a chart audit on the received chart. The Chart Audit being completed by the receiving site shall be completed by the Clinical Supervisor. If there is any missing documentation the previous clinical supervisor and the regional director shall be notified by e-mail. Once the previous supervisor is notified they will have 1 week to give the correction A Directive has been sent VIA e-mail on this procedure and shall be in effect immediately. the next scheduled annual evaluation shall be completed by the 4/7/18 due date |
709.92(a) 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:
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Observations
Three client records were reviewed for documentation of an individual treatment and rehabilitation plan on January 23-24, 2018. The facility failed to document a timely individual treatment and rehabilitation plan for client record # 1. Client # 1 was admitted into treatment on 5/8/17 and was still active in treatment. An individual treatment and rehabilitation plan was completed for the client on 6/23/17. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 4/16/18, a chart check grid has will be established by the program director and regional director that shows all of the due dates for treatment plans, case conferences, and annuals. The excel chart check grid will be stored within a network folder that is viewable to all counseling staff, allowing for due dates to be viewed and tracked daily. The clinical staff will be educated on the requirement to use the chart tracking grid, the need to check the chart grid weekly. The education on the system shall be completed by 4/16/18 during a staff meeting and shall be documented. During the supervision the chart check grid shall be reviewed, approved current treatment plans shall be logged onto the grid by the supervisor and a deadline for any outstanding work will be issued. the supervisor shall document and discuss any failure to follow the chart grid system in a supervisory note. The system will start to be used as of 4/16/18, and will provide up to date tracking of due date to prevent a late or missing plan as cited. The clinical supervisor shall be responsible for the management of the system. The clinical supervisor shall take the responsibility for managing a caseload and completing treatment plans on time with the patient during the transition periods between. This system shall be ongoing to ensure chart accuracy |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
A physical plant inspection was conducted on January 24, 2017. The facility failed to ensure that the facility's hours of operation was displayed to the general public. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The hours of operation have been re-posted on the outside main door entrance for public view to replace the previous ones torn off. To ensure the hours remain posted on the door, the Program Director shall check weekly and replace the sign if it is damage or missing. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
A physical plant inspection was conducted on January 24, 2017. The facility failed to ensure that a telephone number was displayed to the general public for emergency purposes. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The hours of operation have been re-posted on the outside main door entrance for public. The telephone number is displayed on this notice that the general public can call for a emergency purpose. To ensure the hours and emergency contact notice remain posted on the door, the Program Director shall check weekly and replace the sign if it is damage or missing. |