INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on November 16, 2023 through November 17, 2023 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of five personnel records, the facility failed to maintain documentation that counselor assistants received direct observation as part of their close supervision, in two of two applicable records.
Employee # 4 was hired by the facility as a counselor assistant on August 29, 2023. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
Employee # 5 was hired by the facility as a counselor assistant on September 20, 2023. The supervision notes provided at the time of the inspection did not indicate that direct observation of the provision of counseling services was a part of the close supervision.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The regional director shall send an instructional memo to the supervisors of the facility detailing the supervision process for an assistant counselor by 12/20/23. The memo will highlight the need to document the action of completing a direct observation session within the supervision notes of the assistant counselor. The direct observation shall be completed in an individual or group therapy session. Direct observation will start as of 12/20/23 and will be ongoing. To ensure complete the QI department will review supervision notes quarterly to ensure completion |
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.
|
Observations
Based on a review of five personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 4 hours of TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 3 was hired as a counselor assistant on July 18, 2022 and was due to have the communicable disease trainings no later than July 18, 2023. However, there was no documentation of the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 11/30/2023 a google share drive document has been established to track the training requirements for staff for the site. 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 trainings with the staff member and assist with locating trainings 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 trainings to complete. The first email notification shall be sent within 30 days (12/30/23) and the program director shall monitor for completion. The employee referenced is scheduled for the training and shall complete it within the next 30d days |
704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
|
Observations
Based on a review of five personnel records, the facility failed to ensure that at least one-half of all training was provided by trainers not directly employed by the project in one of one applicable record reviewed.
Employee # 3 was hired as a counselor assistant on July 18, 2022. The employee ' s training that was reviewed was between July 18, 2022 and July 17, 2023. Each training completed during the period reviewed, was facilitated by an employee of the project.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The regional director shall send an instructional memo to the supervisors of the facility detailing different training hour requirements for an assistant counselor over a full counselor. The memo will state that all assistant counselors will be required to complete at least 40 hours of training within the anniversary date of their hire. The memo will state that the assistant counselor will ensure that half (20 hours) of the trainings will be completed from a external source. The regional director shall send an instructional memo to the supervisors by 12/20/23. Quarterly, the HR assistant will review the assistant counselor's training grid and email the audit results to the counselor and supervisor. Training hours will be reviewed and document in supervision monthly with the assistant counselor to ensure completion |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of fire drill logs from February 2023 through October 2023, the facility failed to ensure that fire drill logs included the exit route used. The exit route was missing on the October 2023 fire drill log.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 12/20/23, the regional project director will send an instructional memo to the staff of the facility by e-mail regarding the fire drill procedure. The memo will instruct the supervisor staff to include the exit route used on the fire drill form. At the close of each month, the program director will be responsible to review the completed fire drill form to ensure it is complete and accurate. This process will start as 12/20/23 and shall be ongoing. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
|
Observations
Based on a review of client records, the facility failed to ensure that verbal medication orders were authenticated in writing by a physician or other medical professional within three business days in one of one applicable record reviewed.
Client # 8 was admitted on March 21, 2023 and was discharged on September 30, 2023. A verbal order was given on May 24, 2023, and was not authenticated in writing.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
As of 12/11/23 the regional project director has sent a request Soar's EMR vendor to have a new audit report for verbal orders created within the EMR system. The audit report will identify verbal medication orders that have not been authenticated in writing by a physician or other medical professional within three business days. If a verbal order is found, the order shall be authenticated in writing by a physician or other medical professional. The audit system will be developed by the ERM vendor by 1/15/24. Weekly the nurse mange shall run the audit report to locate verbal orders need to be authenticated and present them to the MD. The process will be monitored by the QI department to ensure completion |
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
|
Observations
Based on the review of four months of physician and physician ' s assistant timesheets, the facility failed to provide at least one hour of physician time a week on site for every ten patients in three weeks reviewed.
During the week of July 2, 2023 through July 8, 2023, the patient census was 215. The facility was required to provide at least 21.5 physician hours. There were 0 hours documented.
During the week of August 20, 2023 through August 26, 2023, the patient census was 203. The facility was required to provide at least 20.3 physician hours. There were 18.5 hours documented.
During the week of August 27, 2023 through September 2, 2023, the patient census was 204. The facility was required to provide at least 20.4 physician hours. There were 6.5 hours documented.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Soar is currently making an effort to hire an additional MD to extend service hours for the patients and to provide vacation coverage for the existing MD's. The CEO of Soar will be responsible for the recruitment and hiring of an additional MD within the next 90 days. The recruitment and hiring of a MD shall be ongoing. The ratio of MD hours to patient census shall be monitored by the QI department to ensure compliance |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
|
Observations
Based on the review four months of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census for two weeks reviewed. A physician must provide one-third of the required hours, with a certified registered nurse practitioner or physician's assistant providing the remaining two-thirds of the required hours.
During the week of August 20, 2023 through August 21, 2023, the patient census was 203. The physician was required to provide one-third of the 20.3 hours, which equals to 6.76 hours. The physician provided 6.5 hours.
During the week of August 27, 2023 through September 2, 2023, the patient census was 204. The physician was required to provide one-third of the 20.4 hours, which equals to 6.8 hours. The physician provided 6.5 hours.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Soar is currently making an effort to hire an additional MD to extend service hours for the patients and to provide vacation coverage for the existing MD's. The CEO of Soar will be responsible for the recruitment and hiring of an additional MD within the next 90 days. The recruitment and hiring of a MD shall be ongoing. The ratio of MD hours to patient census shall be monitored by the QI department to ensure compliance |
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to complete a random urinalysis at least monthly in one of seven patient records reviewed.
Patient # 10 was admitted on May 26, 2020 and was active at the time of the inspection. There was no documented drug screen urinalysis in the record, for the month of July 2023.
This is a repeat citation from the January 26, 2023 through January 27, 2023 annual renewal licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 12/20/23, the nursing manager will run a "patient without a uds report" from the EMR system twice a month to identify the patients who have not completed the minimum UDS screening requirements. Patient identified by this method shall be placed on hold to complete a sample. Patients who refuse to complete the screenings shall have a non-billable medical note placed in their emr record to indicate the attempt and refusal to complete. To ensure compliance at the end of each month, the qi staff shall run "patient without a uds report" and audit the patient's chart for a nonbillable note. A chart lacking a nonbillable note shall be sent to the nursing manager for correction. The process will be ongoing as of 12/20/23. |
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.
|
Observations
Based on a review of patient records, the facility failed to ensure an annual physical examination was given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in two of three applicable records reviewed.
Patient # 6 was admitted on February 20, 2013 and was discharged on March 16, 2023. The annual physical examination was due no later than February 20, 2023; however, the most recent annual physical was completed on February 15, 2022.
Patient # 9 was admitted on March 1, 2018 and was discharged on September 15, 2023. The annual physical examination was due no later than March 1, 2023; however, the most recent annual physical was completed on March 14, 2023.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 12/11/23 the regional project director and Soar's EMR vendor to have built an audit tool / report for annual physical exam entitled MD physical report. The audit report will identify patient MD physicals that will be due within 30 days of running the report and will also identify any late reviews. Weekly the patient MD Physical report will be run by the clinical supervisor and patients due for a annual will be scheduled by the medical administrative staff. A management team member will document non-compliance with attending a annual review in the patient's emr file to serve as proof that attempts were made by the facility. The process will be monitored by the QI department to ensure completion. The process of completing the weekly audit report will begin as of 12/20/23 and be ongoing |
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.
|
Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of each patient's status was completed by the patient's counselor in one of three applicable records reviewed.
Patient # 6 was admitted on February 20, 2013 and was discharged on March 16, 2023. An annual evaluation was due to be completed by February 20, 2023, however, the most recent annual evaluation was completed on February 18, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The regional director shall send an instructional memo to the supervisors and the clinical staff of the facility reviewing the guidelines of the clinical annual review. The memo will state that the clinical annual review must be completed by the anniversary date of the patient's admission into the program. The memo will outline the domains to be completed within the review and the required signatures. The memo shall be sent by 12/29/23. Weekly audit report 151 e "Clinical Annual Review by Caseload" will be run by the clinical supervisor to identify upcoming and overdue review. The report will be sent to the clinical staff by email. The clinical supervisor will discuss outstanding clinical annuals identified by this manner in the supervision sessions. The process will be monitored by the QI department to ensure completion. The process of completing the weekly audit report will begin as of 12/29/23 and be ongoing |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within thirty days of admission, per policy, in three of five applicable records reviewed.
Client # 3 was admitted on March 7, 2023 and was active at the time of the inspection. The client record did not contain a psychosocial evaluation.
Client # 4 was admitted on February 2, 2023 and was discharged on August 24, 2023. The psychosocial evaluation was not completed until April 17, 2023.
Client # 8 was admitted on March 21, 2023 and was discharged on September 30, 2023. The psychosocial evaluation was not completed until April 27, 2023.
These finding were discussed with facility staff during the licensing process.
|
Plan of Correction
The regional director shall send an instructional memo to the supervisors and the clinical staff of the facility detailing the process for a psychosocial evaluation. The memo shall be sent by 12/20/23. The memo will state that the psychosocial evaluation must be completed within thirty days of admission for all new intakes. Weekly the QI department will audit new admissions to identify missing or incomplete evaluations. Once identified, the QI department will send a report to the clinical staff by email. The clinical supervisor will discuss outstanding evaluations identified in the supervision sessions. The process will be monitored by the QI department to ensure completion. The process of completing the weekly audit report will begin as of 12/20/23 and be ongoing. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four of nine records reviewed.
Client # 5 was admitted on June 20, 2023 and was discharged on October 7, 2023. The treatment plans completed on June 20, 2023 and September 22, 2023, indicated that the client was to receive one individual session and one group session per week; however, the record contained no documentation of an individual session the weeks of July 3, 2023, July 17, 2023, July 24, 2023, August 7, 2023, or August 21, 2023. Additionally, only five group sessions were documented between July 7, 2023 and the date of discharge.
Client # 8 was admitted on March 21, 2023 and was discharged on September 30, 2023. The treatment plans completed on April 7, 2023 and July 7, 2023, indicated that the client was to receive one group session per week; however, there was no documentation of a group session the weeks of July 17, 2023 and August 7, 2023.
Client # 9 was admitted on March 1, 2018 and was discharged on September 15, 2023. The treatment plan completed on May 23, 2023, indicated that the client was to receive one group session per week; however, the record contained no documentation of group sessions between June 14, 2023 and July 11, 2023.
Client # 10 was admitted on May 26, 2020 and was active at the time of the inspection. The treatment plans completed on April 17, 2023 and June 13, 2023, indicated that the client was to receive one individual session and one group session per week; however, the record contained no documentation of groups session in the month of June 2023. Additionally, the record only documented one individual session per month during May, June, and July 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The program director shall complete a training with the supervisors and the clinical staff of the facility on treatment and rehabilitation services. The training shall be offered by 1/15/24. The training will focus on methods to ensure counseling services are provided according to the individual treatment and rehabilitation plan. The training focus on ways to document a patient who is non-compliant with their treatment and rehabilitation services as outlined in their treatment plan. The training will also focus on updating the frequency of group and individual attendance on a patient's treatment plan to reflect current requirements. Post training, the program director / clinical supervisor will run a "patient not counseled report" to identify the patients who have missed therapy sessions. The clinical supervisor will cross check the system to ensure the n these non-billable notes are entered. Occurrences of a missed session note not being present shall be addressed by the supervisor and a correction by the counselor shall be completed. Monitoring shall begin on 1/15/24 after the training is completed |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
|
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within 24 hours of the date of service, per the facility's policy, in five of ten applicable records reviewed.
Client # 1 was admitted on February 21, 2023 and was active at the time of the inspection. The record contained progress notes for individual sessions occurring on June 26, 2023, July 12, 2023, and July 31, 2023, that were not completed until July 7, 2023, July 18, 2023, and August 10, 2023, respectively.
Client # 4 was admitted on February 2, 2023 and was discharged on August 24, 2023. The record contained progress notes for individual sessions occurring on June 20, 2023, June 26, 2023, and August 4, 2023, that were not completed until June 30, 2023, July 5, 2023, and August 10, 2023, respectively.
Client # 5 was admitted on June 20, 2023 and was discharged on October 7, 2023. The record contained progress notes for individual sessions occurring on August 2, 2023 and August 16, 2023, that were not completed until August 12, 2023 and September 2, 2023.
Client # 7 was admitted on November 17, 2022 and was discharged on July 17, 2023. The record contained progress notes for individual sessions occurring on May 24, 2023, May 31, 2023, June 14, 2023, June 21, 2023, and June 28, 2023, that were not completed until May 30, 2023, June 5, 2023, June 20, 2023, July 1, 2023, and July 5, 2023, respectively.
Client # 8 was admitted on March 21, 2023 and was discharged on September 30, 2023. The record contained progress notes for individual sessions occurring on July 7, 2023, August 4, 2023, and August 18, 2023, that were not completed until July 12, 22023, August 14, 2023, and August 24, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 12/11/23, Soar's regional project director has changed its own internal policy 60002 and 60043 regarding progress notes. The change in the internal policy will now state that the progress notes for group and individual sessions shall be completed within 48 hours to allow ample time for weekend services to be entered. Ongoing, to ensure the notes are completed timely, the counseling staff will send an email daily to their immediate supervisor to indicate the sessions completed on that day. The clinical supervisor will cross check the system to ensure the notes are entered in a timely manner. Occurrence of notes not being timely will be addressed in supervision. The process will start as of 12/20/23 and will be ongoing |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
|
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes every three months for the first year of treatment and annually thereafter, per the facility's policy, in three of nine applicable records reviewed.
Client # 6 was admitted on February 20, 2013 and was discharged on March 16, 2023. A case consultation was documented on February 18, 2022 and another consultation was due to be completed by February 18, 2023; however, no subsequent case consultations were documented in the record.
Client # 7 was admitted on November 17, 2022 and was discharged on July 17, 2023. A case consultation was documented on February 15, 2023 and another consultation was due to be completed by May 17, 2023; however, the next consultation was not completed until May 24, 2023.
Client # 8 was admitted on March 21, 2023 and was discharged on September 30, 2023. The first case consultation was due to be completed by June 21, 2023; however, the case consultation was not completed until July 14, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 12/11/23, Soar's regional project director has changed its own internal policy 60002 regarding case conference notes. The modification will now read "Case Consultation Notes- Case Consults are done at the 6 month point from the point of admission. Additional case conference notes shall be entered on a as needed basis." A copy of the revised policy will be issued to the clinical staff as of 12/20/23. Ongoing, to ensure the case consults are completed timely, the QI department on a monthly basis will run the admission for the last 6 months report to identify upcoming consults that will be due. Once identified, the QI department will send a report to the clinical staff by email. The clinical supervisor will discuss the completion of and the need to complete any outstanding case consults in the supervision sessions. The process will be monitored by the QI department to ensure completion. The process of completing the weekly audit report will begin as of 12/20/23 and be ongoing.
|
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information at 30- and 90-days post discharge, per facility policy, in four of five applicable records reviewed.
Client # 4 was admitted on February 2, 2023 and was discharged on August 24, 2023. The client record did not contain documentation of follow-up information.
Client # 5 was admitted on June 20, 2023 and was discharged on October 7, 2023. The client record did not contain documentation of follow-up information.
Client # 7 was admitted on November 17, 2022 and was discharged on July 17, 2023. The follow-up was not documented in the record until August 29, 2023.
Client # 8 was admitted on March 21, 2023 and was discharged on September 30, 2023. The follow-up was not documented in the record until November 13, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 12/11/23, Soar's regional project director has changed its own internal policy 60002 regarding case discharge follow up. The modification will now read All members who have been discharged will, with the written consent of the member, receive a follow up attempt from the program to determine the member's disposition. The members will be contacted within in thirty (30) days after their discharge date". As of 12/11/23, an instructional email has been issued by the regional director to the clinical staff. The instructional email states timelines for follows and reviews the process to document the follow in the EMR system. The QI department will run the discharge follow up report in the emr system to identify missing or incomplete follow ups. Once identified, the QI department will send a report to the clinical staff by email. The clinical supervisor will discuss outstanding follow ups in the supervision sessions. The process will be monitored by the QI department to ensure completion. The process of completing the weekly audit report will begin as of 12/20/23 and be ongoing. |