INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 27, 2021 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on one of five employee records reviewed, the facility failed to document a written individual training plan for each employee, appropriate to that employee's skill level developed annually with input from both the employee and the supervisor.
Employee # 4 was hired as a counselor on February 11, 2019 and was still in this position at the time of the inspection. The last documented training plan for employee # 4 was on February 11, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Training and Development Manager will develop a training plan for the project. The Program Manager will meet with staff and their direct supervisor, to review their job specific training plans by September 30th, 2021. Annually, the Program Director and Supervisors of the program will review the comprehensive training plans developed by the Training and Development Manager that is based on job specific identified needs and submit plans to HR by December 15th of each year. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on one of five employee records reviewed, the facility failed to provide documentation of at least twenty-five clock hours of training annually for employee # 4.
Employee # 4 was hired as a counselor on February 11, 2019 and was still in this position at the time of the inspection. Employee # 4 had only 8 clock hours of trainings for the training year 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director, with the assistance of the Training and Development Manager, will assess each staff for DDAP training requirements and assess individual training deficits. The Program Director will work with staff and their supervisors to ensure staff have the appropriate number of training courses. Completion of these courses will be submitted to HR via Relias. New hires will add these requirements to their annual training plan. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to ensure all utensils are stored in a clean enclosed area after each use. Silverware and cooking utensils were not stored in an enclosed area or covered when not in use.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All silverware will be stored in containers that are covered. All cooking utensils will be stored in drawers. Coverings for silverware were purchased and in place by the time of this POC. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility had a space heater located in the director's office that was not permanently mounted or installed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All space heaters or other heating devices that are not permanently mounted or installed, have been removed by the time of this POC. |
705.10 (c) (2) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
(ii) The extinguisher shall be located near an exit and away from the cooking area.
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Observations
Based on a physical plant inspection, the facility failed to mount the fire extinguisher away from the cooking area and near an exit. The fire extinguisher located in the kitchen was mounted on the kitchen island in front of the stove.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire extinguisher has been moved to a location that is near the kitchen as of the time of this POC. This new location is away from the cooking area. |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on two of two applicable client records reviewed, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include a discharge summary.
Client # 9 was admitted on October 2, 2020 and was discharged on November 5, 2020. There was not a discharge summary in the client record.
Client # 10 was admitted on July 4, 2020 and was discharged on July 29, 2020. There was not a discharge summary in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed findings with the Clinical Coordinator and Clinical team. Implementation of monthly documentation audits will begin 06/30/2021. The Program Director will ensure implementation and monitor that deficiencies will be addressed and resolved within 72 hours. |
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 two of two applicable client records reviewed, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include follow up information in accordance with the facility's policy and procedure manual. The facility's policy and procedure manual indicates follow-up information to occur within 7 days of discharge.
Client # 9 was admitted on October 2, 2020 and was discharged on November 5, 2020. There was not follow-up information in the client record.
Client # 10 was admitted on July 4, 2020 and was discharged on July 29, 2020. There was not follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up information shall be documented in the client chart by the staff that is performing the follow up. This documentation includes verbal conversations, in person meetings and virtual meetings. These will be documented via a memo to chart each occurrence. Implementation and deficiency correction will be monitored by the Program Director via monthly chart audits. Any deficits will be remedied within 72 hours. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on five of six client records reviewed, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include case consultations in accordance with the facility's policy and procedure manual. The facility's policy and procedure manual indicates a case consultation to occur for inpatient care within 7 days.
Client # 1 was admitted on April 30, 2021 and was still active at the time of the inspection. There was not a case consultation completed weekly in the client record.
Client # 2 was admitted on April 27, 2021 and was still active at the time of the inspection. There was not a case consultation completed weekly in the client record.
Client # 4 was admitted on May 3, 2021 and was still active at the time of the inspection. There was not a case consultation completed weekly in the client record.
Client # 7 was admitted on June 17, 2020 and was discharged on July 25, 2020. There was not a case consultation completed weekly in the client record. The first case consultation occurred on July 10, 2020.
Client # 8 was admitted on October 12, 2020 and was discharged on November 10, 2020. There was not a case consultation completed weekly in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment team will occur with the clinical team each week. Case consultation notes will be documented during treatment team. All applicable admissions, LOC changes and discharges will be reviewed by the clinical team. Documentation will be kept by electronic record. Case consultation will be added to the monthly chart audit to ensure compliance. Implementation of this process began 06/01/2021 and will occur no less than weekly or as needed. Treatment team minutes will be monitored by the Program Director. |
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 two of two applicable client records reviewed, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include a discharge summary.
Client # 7 was admitted on June 17, 2020 and was discharged on July 25, 2020. There was not a discharge summary in the client record.
Client # 8 was admitted on October 12, 2020 and was discharged on November 10, 2020. There was not a discharge summary in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director reviewed findings with the Clinical Coordinator and Clinical team. Implementation of weekly documentation audits will begin July 1st 2021. Any deficits will be addressed and resolved within 72 hours. The Program Director will ensure implementation. |
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 two applicable client records reviewed, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include follow up information in accordance with the facility's policy and procedure manual. The facility's policy and procedure manual indicates follow-up information to occur within 7 days of discharge.
Client # 7 was admitted on June 17, 2020 and was discharged on July 25, 2020. There was not follow-up information in the client record.
Client # 8 was admitted on October 12, 2020 and was discharged on November 10, 2020. There was not follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 9-10, 2019 annual inspection.
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Plan of Correction
The Program Director reviewed findings with the Clinical Coordinator and Clinical team. Implementation of weekly documentation audits will begin July 1st 2021. Any deficits will be addressed and resolved within 72 hours. The Program Director will ensure implementation. |