INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18-19, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SOAR Corporation Chester was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant to complete an annual audit of financial activities associated with the project's drug/alcohol abuse services at the end of the facility's fiscal year.
The findings include:
The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on November 22, 2013. The last fiscal audit was dated February 28, 2012 for fiscal years ending September 30, 2011 and September 30, 2010. There was a review completed by an audit company June 17, 2013, but they stated in the review that they did not audit the financial books and therefore were not rendering an opinion. The project/facility director reported that the project is now on a calendar year rather then a fiscal year for reporting.
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Plan of Correction
As of December 13, 2013, the Regional Project Director has spoken to the board of SOAR CORP about the need to complete independent audits. The Board of SOAR CORP has authorized the completion of a audit for Jan 1, 2012 through December 31, 2012 and a audit for Jan, 1 2013 through december 31, 2013 time periods. An independent audit company shall be retained by the Board and the Regional Project Director to complete the audits by 2/1/14. The regional project director shall monitor to ensure the completion of both audits |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to include the reason for termination in the written notice of a decision to involuntarily terminate in two of two client records reviewed.
The findings include:
Eight client records were reviewed November 18-19, 2013. Two required written notice of the reason for being involuntarily terminated.
Client # 7 was admitted December 27, 2012. The client was given written notice of a decision to involuntarily terminate the client on September 17, 2013. However, the facility uses a generic form that lists categories to be checked. Noncompliance with facility rules was checked, but did not inform the client of the specific form of noncompliance. The form does not allow for the facility to include the actual reason for the termination.
Client # 8 was admitted April 10, 2012. The client was given written notice of a decision to involuntarily terminate the client on August 6, 2013. However, the facility uses a generic form that lists categories to be checked. Noncompliance with facility rules was checked, but did not inform the client of the specific form of noncompliance. The form does not allow for the facility to include the actual reason for the termination.
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Plan of Correction
The Executive Director of the program has now completed a revision of the current Administrative Withdrawal from Treatment. The revised form will still lists categories to be checked but now includes a text box to state the specific actual reason /violation causing the termination. As of 12/2/13, the Executive Director has issued an instructional memo to all the clinical staff stating the procedure to completing the revised form. The executive Director shall review all completed administrative discharge forms to ensure it is completed correctly, incomplete or incorrect forms shall be returned to the counselor who completed it for corrections. The new form will be used as of 12/9/13 by all clinical staff |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to ensure a psychosocial evaluation was completed in one of five client records reviewed.
The findings include:
Eight client records were reviewed November 18-19, 2013. Five were reviewed specifically for psychosocial evaluations.
Client # 3 was originally admitted December 2012. The client was discharged and then re-admitted September 4, 2013. The history from the original admission was reviewed, but a psychosocial evaluation was not completed.
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Plan of Correction
The Executive Director shall complete an in-service training for all clinical staff in regards to the psychosocial assessment and evaluations by 12/16/13. The focus of the in-service will be on time frames for completing the assessment and evaluations for new admission and for readmissions. Staff shall be educated on the need to complete a new psychosocial evaluation of all admission including readmissions and the need to complete a new psychosocial assessment on any readmission when the assessment is more than 6 months old. The completion of the assessments and evaluations shall be monitored by the Executive Director for accurate completion and will be returned to a counselor for corrections as needed. |