INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 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, Silvermist LLC 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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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to include "reasons for removing sections shall be documented in the record" in the client rights policy.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy was updated on 05/18/2023 to include "reasons for removing sections shall be documented in the record". |
709.83(a)(11) LICENSURE Client records
709.83. 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.
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Observations
Based on one of three applicable partial hospitalization client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 7 days after discharge by phone.Client # 12 was admitted on February 3, 2023 and was discharged on February 15, 2023. There was no follow-up information available in the client record. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the July 20, 2022 and May 27, 2021 annual licensing inspection.
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Plan of Correction
Clinical Director will re-educate the clinical team around completing a follow-up call to clients within 7 days of their discharge. These calls will be documented in the client's chart.
Following a client's discharge an alert will be sent to the clinical team to remind them of 7 day follow up call. This has been implemented as of 05/30/2023.
The Regional Quality Manager will review chart audits on a monthly basis to ensure 7-day follow-up calls are being completed within required timeframe. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on one of three applicable residential client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a discharge summary be completed within 48 hours of discharge.Client # 5 was admitted on September 22, 2022 and was discharged on October 3, 2022. The discharge summary was due to be completed no later than October 5, 2022; however, the discharge summary was not completed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review of these citations it was determined to be a training opportunity to on singular clinician. Training and reeducation occurred on 05/31/2023 and ongoing monitoring will occur in individual supervisions moving forward.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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.
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Observations
Based on two of three applicable residential client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 7 days after discharge by phone.Client # 5 was admitted on September 22, 2022 and was discharged on October 3, 2022. There was no follow-up information available in the client record. Client # 7 was admitted on March 3, 2023 and was discharged on March 25, 2023. There was no follow-up information available in the client record. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the July 20, 2022, May 27, 2021, and July 9-10, 2019 annual licensing inspection.
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Plan of Correction
Clinical Director will re-educate the clinical team around completing a follow-up call to clients within 7 days of their discharge. These calls will be documented in the client's chart.
Following a client's discharge an alert will be sent to the clinical team to remind them of 7 day follow up call. This has been implemented as of 05/30/2023.
The Regional Quality Manager will review chart audits on a monthly basis to ensure 7-day follow-up calls are being completed within required timeframe. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for completing and documenting follow-up information for the inpatient records was submitted and approved by the Department for the July 20, 2022, May 27, 2021 and July 9-10, 2019 annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the May 17, 2023 licensing inspection.A plan of correction for completing and documenting follow-up information for the partial hospitalization records was submitted and approved by the Department for the July 20, 2022, and May 27, 2021 annual licensing inspection. Completing and documenting follow-up information was again found to be a deficiency in the May 17, 2023 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A thorough review of last years plan of correction revealed that completing chart audits monthly did not allow for correction in real time. Moving forward, clinicians will be required to complete a checklist from admission to discharge to ensure all processes are completed timely. |