INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29-31, 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 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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704.6(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 29-31, 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
1. 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
Three personnel records were reviewed for the counselor assistant position on January 29-31, 2018. The facility failed to fully document the required close supervision and direct observation for employee records # 7, 8, and 9. Employee # 7 was hired as a Bachelor's level counselor assistant on 12/6/16. The employee was then promoted to the counselor position on 12/1/17. The employee required close supervision for the first 6 months of employment, which was to include at least 1 hour of direct observation per week. Weekly supervision notes were reviewed for the period of 1/13/17 - 6/29/17. The facility failed to demonstrate that weekly close supervision included at least 1 hour of direct observation once a week. Employee # 8 was hired as a Bachelor's level counselor assistant on 1/8/18. The employee requires close supervision for the first 6 months of employment, which is to include at least 1 hour of direct observation per week. Weekly supervision notes were reviewed for the period of 1/9/18 - 1/23/18. The facility failed to demonstrate that weekly close supervision included at least 1 hour of direct observation once a week. Employee # 9 was hired as a Bachelor's level counselor assistant on 2/8/17. The employee required close supervision for the first 6 months of employment, which was to include at least 1 hour of direct observation per week. Weekly supervision notes were reviewed for the period of 2/15/17 - 8/30/17. Supervision notes were not documented for the following weeks: -Week of 3/19/17-Week of 4/16/17-Week of 4/30/17-Week of 5/14/17-Week of 6/28/17-Week of 7/4/17-Week of 8/13/17-Week of 8/20/17The facility also failed to 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 |
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
Nine personnel records were reviewed on January 29-31, 2018. The facility failed to provide documentation of required STD/TB training for employee record # 4. Employee # 4 was hired on 10/12/16 as a counselor. The employee was due to complete STD/TB training by no later than 10/12/17. Documentation of this training was not found in the employee's record. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The staff member in question will continue to check the DDAP training website weekly and shall register for the next upcoming training in this area on TB/ STD. The clinical supervisor shall review the progress to registering and completing this train and shall document this in a supervision note. as long as the training is offered in this area it shall be completed within the next 90 days. Moving forward, the Human resource director shall monitor the need for required training completion of all new staff and shall send quarterly to each staff member and their supervisor a list of trainings to complete. The list of trainings shall be sent by e-mail to serve as proof of being notified. The supervisor will follow up with the employee, and document discussion, registration and completion of such trainings. Once complete the HR director shall receive a copy of the training for the HR file |
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 29-31, 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 (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
A physical plant inspection was conducted on January 31, 2018. Five storage closets used for the storage of hard copy client records were found to be unlocked. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 3/14/18, the Regional Director has issued an instruction memo to all of the staff of the Chester location regarding chart room procedure. The memo stated the following directives, first, the chart room including the 5 hall closets containing patient records, must be closed and locked at all times and any staff who opens the chart room is responsible to close and lock it. Second, all chart must be returned to the chart room at the close of business to ensure confidentiality of records. Third, staff found to breach this procedure may result in progressive discipline action. The administrative and management staff shall monitor this daily to ensure the door stays closed to protect the records. The memo was sent from the regional director to all staff via e-mail to act as a verification of receipt of the memo
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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
Six client records were reviewed on January 30-31, 2018. The facility failed to obtain a valid informed and voluntary consent to release information for client records # 1, 2, and 6. Client # 1 was admitted into treatment on 7/11/17 and was still active in treatment. A consent to release information to a hospital, signed and dated by the client on 9/27/17, did not specify the date the consent would expire. Documentation in the client's record indicated that the facility faxed information on 1/8/18 to the client's physician at the hospital, reporting the client's medical and treatment status. Client # 6 was admitted into treatment on 6/1/17, as a transfer from another narcotic treatment program, and was still active in treatment. Documentation in the client's record indicated that the facility sent written notification of the client's admission and initial dose to the referring narcotic treatment program on 6/7/17. A consent to release information to the referring narcotic treatment program was not documented in the client's record. 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 on the 255.5 and 42cfr regulations towards patient confidentiality by 5/30/18. Proof of the training shall be kept in the HR binder of the employee. The training shall address the aspects of a valid release i.e. demographics, dates and time periods and the 5 domains of acceptable release of information. The training shall also focus on the need to ensure that the release of information is signed and completed at intake to a referring program prior to sending a confirmation and first dose at our program. Post training, the clinical supervisor of the program will complete a chart audit on all intake charts within 30 days of the admission date, to examine and identify issues with releases. If any errors are observed the clinical supervisor shall have the counselor correct and return the chart for review to the clinical supervisor within 1 week. The check and balance process will be ongoing |
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
Six client records were reviewed on January 30-31, 2018. The facility failed to document the provision of a random urinalysis at least monthly for client records # 4 and 6.Client # 4 was admitted into treatment on 2/7/17 and was discharged on 11/4/17. Documentation of a random urinalysis completed in the month of March 2017 was not found in the client's record. Client # 6 was admitted into treatment on 6/1/17 and was still active in treatment. Documentation of a random urinalysis completed in the month of October 2017 was not found in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Charge Nurse will now pull a report from our electronic medical record system for three locations entitled "no urine drug screen within a month" This report is located under the lab management tab and will develop a list of all patients who have outstanding uncollected urine screens within the month. The charge nurse will run this report by the 20th of each month to identify any uds screens that are outstanding and schedule the patient to complete a screening. In addition The Charge Nurse shall send out an instruction memo to the nursing department staff. 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 an ongoing process. This plan shall be immediate and be ongoing. The regional Project Director shall receive a end of the month report on the 30th of each month from the charge nurse to serve as verification the plan is followed |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Six client records were reviewed on January 30-31, 2018. As the referring narcotic treatment program, the facility failed to transfer all required patient files to the receiving narcotic treatment program for client record # 4. Client # 4 was admitted into treatment on 2/7/17 and was discharged on 11/4/17, upon transferring to another narcotic treatment program. The facility failed to document the transfer of the client's medical summaries, the physical examination and determination of addiction, to the receiving narcotic treatment program. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Regional Project Director shall complete an internal training on the transfer process by 4/30/18. Proof of the training shall be kept in the HR binder of the employee. The training shall address and state the need to send all of the medical and psychosocial summaries, urinalysis reports or summary, and the current status of the patient as outlined by regulations. The staff will be informed of the need to keep the fax confirmation with the transfer package within the patient chart to be proof of the package being sent. The staff will be informed of the need to send all of the required information even when the receiving provider states they do not wish to receive the information. Post training, all counselors shall bring a transfer package to a clinical supervisor for approval prior to being faxed to ensure all required documents are provided. All transfer patients shall be audited by a clinical supervisor at the time of closing a chart to ensure completion. |
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
Six client records were reviewed on January 30-31, 2018. For client record # 5, the facility failed to properly demonstrate that the client was given a fair review of their grievance by the narcotic treatment program director. Client # 5 was admitted into treatment on 3/15/16 and was administratively discharged on 7/27/17. The client was placed on an administrative detox schedule, effective 7/15/17 - 7/22/17. Based on a review of the client's record and the facility grievance log, the client filed a grievance against the termination on 7/18/17. A progress note dated 7/18/17 indicated that the counselor informed the client that their grievance would not discontinue the administrative detoxification. Documentation in the client's record and facility grievance log 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 inspection.
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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. After the grievance is heard, 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. The form to document the hearing outcome is drafted and ready for use. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Six client records were reviewed on January 30-31, 2018. The facility failed to document the provision of an annual physical examination for client record # 3. Client # 3 was admitted into treatment on 2/20/13 and was still active in treatment. The last annual physical examination documented in the client's record was conducted by the physician on 12/11/16. A subsequent annual physical examination was due to be conducted by 12/11/17, and one 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 regional Director and Program Manager have built a excel physical grid that automatically highlights upcoming physicals 30 days prior to the due date. The physical grid is reviewed weekly by a administrative support staff who now schedules to physical prior to the due date. New patients from intake are added to the tracking system at the time of intake. The program manager shall receive a list of schedule appointments weekly from the administrative support staff and will verify all appointments are scheduled. Patient 3 referenced in the report has completed a physical as of 2/8/2018 |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Six client records and the facility's administrative documentation were reviewed on January 29-31, 2018. Based on a review of documentation found in client record # 5 and the facility's incident report log, the facility failed to report the Department an incident that had the potential to cause a negative community reaction or lead to community concern. Client # 5 was admitted into treatment on 3/15/16 and was administratively discharged from treatment on 7/27/17. Documentation in the client's record indicated that a facility staff person observed the client buying illicit drugs from another client on 7/14/17, while on the premises. Documentation in the client's record also noted that the incident was captured on the facility's security cameras. This event was not documented in the facility's incident report log. Facility staff also confirmed that a written Unusual Incident Report for this event was not submitted to the Department. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
11. The clinical supervisor of the program shall fax the incident report referenced by 3/23/18. the clinical supervisor of the program shall complete a internal training with by 3/30/18. The proof of completion of the training shall be placed within the staff's hr binder. The training will include a review of the types of reportable incident reports by state guidelines, provide instruction on how to complete the forms, instruct the staff member to give the report to the clinical supervisor for review and accuracy, and then fax the report and needed. The clinical supervisor shall attach the fax confirmation to the report to show as proof of being sent and store the sent reports in a incident report binder. |
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
Six client records were reviewed on January 30-31, 2018. The facility failed to document a treatment plan update at least every 60 days for client records # 3 and 5. Client # 3 was admitted into treatment on 2/20/13 and was still active in treatment. The last two treatment plan updates documented in the client's record were completed on 9/17/17 and 1/7/18. Client # 5 was admitted into treatment on 3/15/16 and was discharged on 7/27/17. The last treatment plan update documented in the client's record was completed on 4/15/17. A subsequent treatment plan update was due to be completed by 6/15/17, and one was not documented in the client's record. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 3/16/18, a chart check grid has been established by the clinical supervisor and regional director that now shows all of the due dates for treatment plans, case conferences, and annuals. The excel chart check grid is 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 3/21/18 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 4/1/18, 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 |