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 20, 2024 through November 21, 2024 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the educational qualifications for the position in one of three applicable personnel records reviewed.
Employee # 5 was hired as a counselor on September 10, 2024 and was still in the position at the time of the inspection. The employee has a bachelor's degree with a major in political science; however, a political science college major is not a related-field qualifying major.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 12/31/2023, the employee referenced in the review shall sign a new job description and completed a new training plan for the position of assistant counselor from a full counselor. Supervision status will be moved to weekly to comply with regulations. The employee referenced will explore a CADC to meet standards. As of 12/31/2023, Human Resources will now refer to DDAP list of approved degree majors to verify the potential employee's degree and major meet qualifications for the position of counselor. The act of verifying the major will be ongoing |
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 two of four applicable personnel records reviewed.
Employee # 4 was hired as a counselor on September 26, 2023 and was due to have the HIV/AIDS training and the TB/STD training completed no later than September 26, 2024. The TB/STD training was not completed as of the date of the inspection.
Employee # 10 was hired as an administrative support on August 17, 2022 and was due to have the HIV/AIDS training and the TB/STD training completed no later than August 17, 2024. Both trainings were not completed as of the date of the inspection.
This is a repeat citation from the November 17, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
12/13/2024, a google 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 training with the staff member and assist with locating training 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 training to complete. The first email notification shall be sent within 30 days (1/13/2025) and the two staff referenced in the report shall schedule for the training referenced within the next 60 days. the program director shall monitor for completion. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all stairways, hallways, and exits from rooms and from the facility were unobstructed at all times.
At approximately 11:00AM on November 21, 2024, the third-floor balcony exit in the clinical building was key-locked from the exterior and was unable to be opened/unlocked from inside the building.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The outside door to the patio will have an auto locking door handle placed on it to ensure it is locked at all times and is easily opened from the inside of the facility. The outside door handle will be changed as of 1/13/2025 by a member of the maintenance team. The site director will ensure that the lock is changed. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant inspection, the facility failed to maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
At approximately 11:00AM on November 21, 2024, there was an unlocked basement in the administrative building, which is used for facility storage, with only one exit via a stairwell. Additionally, on the second floor of the administrative building, there were 2 separate stairwell exits; however, they are less than 15 feet apart from each other.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/10/2024, the regional project director has submitted an exemption to 705.28 (a) (1) (ii). The exits were approved by DDAP at the initial license and over the last 8 years for use.The exemption filed has requested the continued use of the two stair cases referenced as exits. If allowed, Soar will only allow 2 staff offices within the area and will ensure patient activities are not completed on the 2nd floor to reduce congestion. If a exception is not granted, Soar will have to remove 3 group rooms from service, to convert them to staff offices and a chart in order to move programming from the area referenced. Additionally, the basement door referred will have an auto locking door handle placed on it to ensure it is locked at all times but can be opened from the inside. The basement door handle will be changed as of 1/13/2025 by a member of the maintenance team. The site director will ensure that the lock is changed. |
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 March 18, 2024 and was discharged on August 1, 2024. The release of information form to the funding source was signed by the client on April 10, 2024; however, there was evidence of disclosures to the funding source prior to when the consent to release information form was signed by the client.
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 1/13/2025. 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. Training will cover the need to ensure the specific names of emergency contacts, and others must be listed within the ROI being signed. 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 of QI reviews for ROI's will start as of 1/2/2025 and shall be ongoing |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to a receiving narcotic treatment program for a transferring patient in one of one applicable patient record reviewed.
Client # 5 was admitted on March 18, 2024 and was transferred to another narcotic treatment program on August 1, 2024. There was no documentation in the record indicating what materials were sent to the narcotic treatment program on behalf of the transferring patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Vendor of the EMR system has developed a new system in the electronic patient file to document a transfer request. All transfer outs will now be documented electronically, and shall include the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and the current status of the patient When a patient makes a transfer request, the primary counselor will send an email to the program director with 24 hours of the request. The counselor will complete the transfer documents in the emr system, sending the required documents to the outside provider within 7 days of the request. To ensure completion, the program director will audit the patient chart upon receiving a notification of transfer to ensure the documentation is complete. Occurrences of missing or incomplete document will be addressed by the program director for correction an instruction memo explaining process will be issued by 1/13/2025 by email from the regional director and the system will be used as of 1/13/2025. |
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 July 17, 2024 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 finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Vendor of the EMR system has developed a new system in the electronic patient file to document a transfer request All transfer in's will now be recorded and documented electronically, and shall include the initial dosing information, last dose information, admission date, dosing records. When a patient makes transfers in, the intake counselor will send an email to the program director with 24 hours of the request. The counselor will complete the transfer in documents in the emr system, sending the required documents to the outside provider within 24 hours of the admission date. To ensure completion, the program director will audit the patient chart upon receiving a notification of a transfer in to ensure the documentation is complete. Occurrences of missing or incomplete document will be addressed by the program director for correction an instruction memo explaining process will be issued by 1/13/2025 by email from the regional director and the system will be used as of 1/13/2025. |
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 plans in five of seven applicable records reviewed.
Client # 1 was admitted on April 18, 2024 and was still active at the time of the inspection. The treatment plan and treatment plan updates, completed on May 15, 2024, July 12, 2024, September 12, 2024, and November 12, 2024, indicated the client was to receive two individual sessions and two group sessions per month; however, there was only documentation of the client receiving one individual session during the months of August 2024 and October 2024. Additionally, there was no documentation indicating group sessions were provided to the client during the months of July, 2024, August 2024, and October 2024, as well as documentation indicating only one group session was provided during the month of September 2024.
Client # 2 was admitted on July 17, 2024 and was still active at the time of the inspection. The treatment plan and treatment plan update, completed on July 17, 2024 and August 15, 2024, indicated the client was to receive two group sessions per month. Also, the treatment plan update, completed on October 10, 2024, indicated the client was to receive one group session per month. However, there were no group sessions documented in the record since the client was admitted to the date of the inspection.
Client # 3 was admitted on June 2, 2022 and was still active at the time of the inspection. The treatment plan and treatment plan updates, completed on February 15, 2024, April 11, 2024, June 6, 2024, August 15, 2024, and October 3, 2024, indicated the client was to receive one individual session and one group session per week (which would result in four individual sessions and four group sessions per month). The record included documentation that one individual session being provided during months of April 2024, May 2024, July 2024, and September 2024; two individual sessions being provided during the months of June 2024 and August 2024; and three individual sessions being provided in October 2024. Also, there were no group sessions documented in the record during the reviewed period.
Client # 5 was admitted on March 18, 2024 and was discharged on August 1, 2024. The treatment plan and treatment plan updates, completed on March 18, 2024, May 14, 2024, and July 18, 2024, indicated the client was to receive one group session per month. There were no group sessions documented in the record during the client's entire treatment episode.
Client # 7 was admitted on May 11, 2022 and was discharged on July 15, 2024. The treatment plan and treatment plan updates, completed on January 2, 2024, March 12, 2024, April 30, 2024, and July 2, 2024, indicated the client was to receive one individual session and one group session per week (which would result in four individual sessions and four group sessions per month). The record included documentation that one individual session was provided during the months of April 2024 and June 2024; and three individual sessions were provided during the months of March 2024 and May 2024. Also, there were no group sessions documented in the record during the reviewed period.
This is a repeat citation from the November 17, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An instructional memo shall be issued by the regional director by 1/13/2025 to the clinical staff regarding patient treatment attendance. The memo will state that the staff is responsible for ensuring that patients attend their mutually agreement upon treatment requirements as indicated on the treatment plans. The memo will state that the program director needs to run the "patients not counseled report" weekly to identify patients who have not completed treatment based on their agreement. The program director will place patients who have not attended their agreed upon session on hold to meet with their counselor. Patients who still fail to attend sessions will have a non-billable not placed in the chart to indicate an attempt was made but patient refused services. The process of placing patients on hold to attend a counseling session and documenting failures to attend will be ongoing by the primary counselor of the patient. This plan will be in effect by 1/13/2025 and the program director will monitor to ensure poc is followed. |