INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection, conducted on December 8 - 9, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of annual training in one of one employee records.The findings include:One employee record was reviewed on December 9, 2014, for documentation of the 2013 annual training. The facility failed to ensure that each counselor completed at least 25 clock hours of annual training, specifically employee # 5. Employee # 5, a counselor was hired 8/31/12. Employee # 5 was required to complete 25 hours of annual training for the 2013 training year. Employee # 5's training file included documentation of 21 training hours.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 1/12/15 the Executive Director and the Human Resource director have developed a excel grid to log counselor trainings hours that has been placed in the management folder within our computer system. All completed counselor trainings and hours will be logged on this grid by the HR Director. The program manager will now be responsible for tracking and enforcing counselor training hours for both full and part time counselors. The program Manager will review the excel training log monthly to identify training needs and hours for counselors. The program manager will then address training needs and training hours during the individual supervision sessions. |
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 fire drill log, the facility failed to set off a fire alarm or smoke detector during each fire drill. The facility failed to comply with an exception granted by the Department, relative to Chapter 705.28(d) (7) that required the facility to provide annual documentation that the alarm system is in working order. The findings include:The facility has an exception to the Department of Drug and Alcohol's physical plant standards for Nonresidential Facilities, Chapter 705.28(d) (7), relative to activating a fire alarm or smoke detector during a fire drill. The exception states: "Since the fire alarm will not be activated during fire drills, documentation that the alarm system is in working order needs to be available for review during licensing inspections. This documentation must be updated on an annual basis." The facility failed to provide annual documentation that verified that the fire alarms and/or smoke detectors were in working order. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The last documented inspection of the fire alarm system was in September of 2013. The CFO and Vice President have given authorization for the inspection and repair has been obtained. The Executive Director has an inspection scheduled for 2/11/15 for the fire alarm system. From this point, the Executive Director will be responsible for scheduling the inspection annually within the first quarter of the year. Documentation of the inspection shall be provided by the fire alarm inspector and will be kept for Soar records. The health and safety committee shall act as a check and balance system by following up with the Executive Director at the end of the first quarter to ensure the inspections completion. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation, including the 2013 annual report, the governing body failed to make an annual report available to the public that included a statement disclosing the names of officers, directors and principal shareholders. The findings include:On December 8, 2014, administrative documentation, including the 2013 annual report, was reviewed. The governing body made the 2013 annual report available to the public on March 26, 2014. However, the governing body failed to include a statement disclosing the names of officers, directors and principal shareholders in the 2013 annual report.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Soar Chester shall include the Board of Directors in its annual report from this point forward in the annual report that they are currently advertising in the local media for public review. The Executive Director shall ensure this is completed and a final review shall be completed by the regional project director to ensure completion. The board of directors shall start to be listed in the 2014 annual report that will be completed early in January of 2015. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.The findings include:On December 8, 2014, the project's administrative records were reviewed for a financial audit. The project's fiscal year runs from January through December. The project failed to document the annual audit for the January through December 2013 fiscal year.These findings were reviewed with facility staff during the licensing process.This is a repeat citation. The facility was previously cited for non-compliance on 11/19/13.
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Plan of Correction
As of December 22, 2014, the Vice President has spoken to the board of SOAR CORP about the need to complete independent audits on the financial activities. The Vice President will be responsible for setting agency budgets. the CFO of Soar Corp will be responsible for ensuring that the audits are completed on a ongoing annual basis. These audits will be completed within the first 6 months of each year. The CFO will achieve these audits by retaining a independent audit company. The Vice President of Soar Corp will be a secondary check and balance and ensure the CFO completes the duty. The 2013 and 2014 audit shall be completed within the first 6 months of 2015 |