INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 13, 2025 through November 14, 2025 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 all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of two applicable personnel records reviewed. Employee # 5 was hired as a counselor assistant on May 28, 2024 and promoted to a counselor on May 28, 2025. The employee was due to have the HIV/AIDs and TB/STD trainings no later than May 28, 2025; however, while the TB/STD training was completed within the timeframe, the HIV/AIDS training was not completed until August 15, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR training grid utilized to track staff training requirements has been posted on electronic drive allowing all staff access to see their training needs. During scheduled supervision sessions, supervisors will now review required trainings with their staff, offering assistance in locating necessary courses as needed. Supervisors will document the outcomes of these discussions in the supervision notes. Additionally, the HR Assistant will conduct a monthly review of the training grid. Within 30 days of this notice (12/24/2025), the HR Assistant will send the first email to all staff, outlining their current training hours and required courses. The Program Director will monitor the employee's progress to ensure completion. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, conducted at approximately 11:00 a.m. on November 14, 2025, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. At the time of the inspection, the tag for one fire extinguisher, located within the facility nursing station, had that it was last inspected in September 2024.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within the next 30 days (12/24/25), the program director will schedule an appointment with the external fire safety vendor to inspect and tag the fire extinguisher located in the nursing station. Moving forward the nursing manager will check the tag quarterly to ensure it is in compliance and report expiration to the program. Process will be ongoing |
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
Based on an administrative review, the facility 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.There was no financial audit for the project's fiscal year ending June 30, 2024 completed as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Within the next 90 days, Soar Corp will contract with an independent certified public accountant to perform an annual financial audit for the project's fiscal year ending June 30, 2024. The CEO of Soar is responsible for this process, with the immediate goal of securing a completed audit within the 90-day timeframe (3/1/2026). The CEO will also ensure all future audits are completed within 90 days of their respective fiscal year-ends to maintain compliance with all relevant standards. |
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 at approximately 11:00 a.m. on November 14, 2025, the facility failed to secure hard copy client records within locked storage containers. There were unsecured client-identifying records sitting on the desk of an unlocked counselor's office, which was not occupied at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The regional project director shall send an instructional memo by email to all staff regarding confidentiality. The memo will state that unsecured client-identifying records in a counselor's office must be returned to the locked storage containers in the chart room when exiting the counselor office and the office is not occupied to ensure confidentiality. The memo will be sent within the next 30 days (12/24/2025). The program director will monitor compliance by checking for open unoccupied office doors during the day. |
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 # 5 was admitted on April 4, 2022 and was discharged on May 12, 2025. There was evidence of a disclosure to another treatment provider on May 12, 2025; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 1/25/2026, the Program Director will provide an internal training on releases and confidentiality. The training will cover proper release formulation, the need for informed and voluntary consent before disclosing information, and a review of 42 CFR regulations. It will also emphasize that specific names of emergency contacts and other individuals must be listed on a signed release of information (ROI). Additionally, the training will address the importance of obtaining consent before sharing transfer-in, transfer-out, and dosing information. Finally, the Program Director and the administrative assistant will conduct a monthly audit of a sample of charts to ensure this procedure is followed. The Program Director will address any ongoing issues during supervision sessions, and proof of the training will be placed in each employee's HR file in the form of a certificate. |
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 narcotic treatment program failed to ensure narcotic treatment physician services were provided at least 1 hour per week onsite for every ten patients for two weeks out of eighteen weeks reviewed. During the week of August 11, 2025 through August 17, 2025, the patient census was 194 and required 19.4 physician hours, but there were only six physician hours documented during the week.During the week of August 18, 2025 through August 24, 2025, the patient census was 193 and required 19.3 physician hours, but there were six physician hours documented during the week. This is a repeat citation from the January 24, 2023, January 5, 2024, and December 3, 2024 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Soar is prioritizing the recruitment of an additional Telehealth Medical Doctor (MD) to immediately expand patient access and address care needs. The new Telehealth MD will assist to manage medication checks and extend overall physician coverage hours. This initiative will ensure continuous clinical coverage, particularly during existing MD vacations. The CEO will personally lead the recruitment and hiring efforts, with the immediate goal of securing additional Telehealth MD hours within 90 days. Concurrently, the CEO will be responsible for establishing an ongoing process for monitoring the MD-to-patient census ratio to maintain continuous compliance with all relevant standards. |
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
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient record reviewed. Patient # 2 was transferred in from another narcotic treatment program and admitted on May 5, 2025 and was still active at the time of inspection. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the client's date of admission and the date the client was given their initial dose. This is a repeat citation from the December 3, 2024 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Project Director issued an instructional memo on November 25, 2025, outlining the following mandatory transfer-in procedure, which becomes effective on December 1, 2025. The Intake Counselor is responsible for initiating and completing all transfer-in procedures, specifically
1. Program Director Notification: The Intake Counselor must notify the Program Director via email within 24 hours of receiving a patient transfer-in request.
2. Documentation Completion: All necessary transfer-in documents must be completed by the intake counselor in the EMR system, and the required documentation must be forwarded to the outside provider within 24 hours of the patient's admission date.
To ensure compliance, the Program Director will audit the patient chart immediately upon receipt of the transfer-in notification. The Program Director will address and manage the correction of any deficient or missing documentation. The process will be ongoing.
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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 a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in six of seven applicable client records reviewed.Client # 2 was admitted on May 5, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 5, 2025 and the first update was due no later than July 5, 2025; however, the update was not completed until October 29, 2025.Client # 3 was admitted on August 23, 2019 and was still active at the time of the inspection. A treatment plan update was completed on May 22, 2025 and another update was due no later than July 22, 2025; however, the update was not completed until July 31, 2025.Client # 4 was admitted on August 11, 2023 and was discharged on September 21, 2025. A treatment plan update was completed on January 8, 2025 and another update was due no later than March 8, 2025; however, the update was not completed until March 19, 2025. Additionally, a treatment plan update was completed on July 1, 2025 and another update was due no later than September 1, 2025; however, it was not completed prior to discharge.Client # 5 was admitted on April 22, 2025 and was discharged on May 12, 2025. A treatment plan update was completed on February 13, 2025 and another update was due no later than April 13, 2025; however, the update was not completed until May 5, 2025.Client # 6 was admitted on June 10, 2025 and was discharged on October 24, 2025. The individual treatment and rehabilitation plan was completed on June 10, 2025 and the first update was due no later than August 10, 2025; however, the update was not completed until October 22, 2025.Client # 7 was admitted on January 19, 2023 and was discharged on September 4, 2025. A treatment plan update was completed on February 12, 2025 and another update was due no later than April 12, 2025; however, the update was not completed until May 7, 2025.This is a repeat citation from the December 3, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Project Director issued an instructional memo on November 25, via email to all Clinical Supervisors and Program Directors on November 25, 2025, mandating a new weekly audit procedure for treatment plans. The EMR Audit Report 147D, titled "Treatment plans due in a date range," will be used weekly to identify all overdue or upcoming treatment plans within a specified reporting period. The Clinical Supervisor is responsible for addressing all instances of missing or incomplete documentation with the assigned Counselor. The Counselor must complete and return the necessary corrections to the Clinical Supervisor within one week of receiving the notification. The process will be ongoing and start as of 12/1/2025 |
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
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in seven of seven applicable client records reviewed.Client # 1 was admitted on May 2, 2025 and was still active at the time of the inspection. The treatment plan and subsequent updates, completed on June 5, 2025, August 8, 2025, and October 8, 2025, indicated the client was to receive one group counseling session per month. The record of services and progress notes indicated the client received no group counseling sessions from admission through the date of the inspection. Client # 2 was admitted on May 5, 2025 and was still active at the time of the inspection. The individual treatment plan, completed on May 5, 2025, indicated the client was to receive one group counseling session per month. The subsequent treatment plan update, completed on October 29, 2025, indicated the client was to receive two group counseling sessions per month. The record of services and progress notes indicated the client received no group counseling sessions from admission through the date of the inspection. Client # 3 was admitted on August 23, 2019 and was still active at the time of the inspection. The treatment plan updates, completed on March 31, 2025 and May 22, 2025 indicated that the client was to receive two group counseling sessions per month. The subsequent treatment plan updates, completed on July 31, 2025 and September 25, 2025, indicated the client was to receive one group counseling session per month. The record of services and progress notes indicated the client received no group counseling sessions from the noted treatment plan updates through the date of the inspection.Client # 4 was admitted on August 11, 2023 and was discharged on September 21, 2025. The treatment plan update, completed on May 5, 2025, indicated the client was to receive one group counseling session per month. The record of services and progress notes indicated the client received no group counseling sessions from the date of the treatment plan update through discharge. Client # 5 was admitted on April 22, 2025 and was discharged on May 12, 2025. The treatment plan update, completed on February 13, 2025, indicated the client was to receive one group counseling session per month. The record of services and progress notes indicated the client received no group counseling sessions from the date of the treatment plan update through discharge.Client # 6 was admitted on June 10, 2025 and was discharged on October 24, 2025. The treatment plan completed on June 10, 2025 and the subsequent treatment plan update completed on October 22, 2025 indicated the client was to receive one group counseling session per month. The record of services and progress notes indicated the client received no group counseling sessions from admission through discharge. Client # 7 was admitted on January 19, 2023 and was discharged on September 4, 2025. The treatment plan updates, completed on February 12, 2025 and May 7, 2025, indicated that the client was to receive one group counseling session per month. The record of services and progress notes indicated the client received no group counseling sessions from the date of treatment plan updates through discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Project Director issued a formal instructional memo via email to all Clinical Staff on November 25, 2025, mandating the following procedure for handling patient non-compliance with required treatment hours. The primary counselor is responsible for ensuring patients attend their mutually agreed-upon treatment requirements as documented in their individual treatment plans. The Program Director must run the "Patients Not Counseled Report" weekly to identify all instances of non-compliance with agreed-upon services. The Program Director will address the identified non-compliance issues directly with the assigned Counselor. Upon notification, the Counselor will place non-compliant patients hold until a meeting with the Counselor occurs. If the patient still fails to attend the required sessions after the intervention attempt, the Primary Counselor must document this in the patient's chart using a non-billable note. This note must clearly state that an attempt was made to provide services, but the patient refused. Program Directors are responsible for monitoring ensure this entire Plan of Correction (POC) is followed by all staff, beginning December 1, 2025. |
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 and patient records, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for failing to ensure narcotic treatment physician services were being provided at least 1 hour per week onsite for every ten patients was submitted and approved by the Department for the December 3, 2024, January 5, 2024, and January 24, 2023 annual licensing inspections. Failing to ensure narcotic treatment physician services were being provided at least 1 hour per week onsite for every ten patients was again found to be a deficiency in the November 13, 2025 through November 14, 2025 annual licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Project Director has formally recommended the creation and hiring of a Quality Improvement (QI) Manager role to the Board of Directors and the Corporate CEO. The QI Manager will complete Conducting continuous audits and follow-up activities related to all issued Plans of Correction (POCs) to ensure full compliance is achieved and sustained. The QI Manager will also ensure clinical staffing ratios and hours for Medical Doctor (MD) and Nursing staff are maintained according to regulatory standards. This compliance data shall be reviewed monthly. The approval and subsequent hiring by the CEO for the Quality Improvement Manager position is projected to be completed by March 1, 2026. |