INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 14 - 15, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to document a fire drill during sleep hours based on a review of the June 2017 - May 2018 fire drill records on June 14, 2018.
The facility's sleep hours are Monday - Friday from 11 PM to 7 AM and Saturday - Sunday from 12 midnight to 8 AM. No drills were conducted during these times.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Silvermist maintenance manager completed an unannounced fire drill during sleep hours immediately following the site inspection and plans to incorporate them into the fire drill schedule once per quarter. The program director will review the firedrill procedures each month during the monthly safety meetings to ensure that the drills are in compliance with DDAP regulations, specifically to ensure that sleep hour drills are being done once per quarter. The program director also reviewed the procedure with staff in order to ensure that they understand the DDAP requirement and procedure. |
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
The facility did obtain an informed and voluntary consent for the disclosure of information contained in the client's record. However, the consent exceeded the limits imposed at 4 Pa. Code 255.5 in seven of seven client records reviewed on June 14 - 15, 2018
The consent to release information form for the insurance company indicated the following information would be released "medication administration record, psychological assessment, history and physical and psychiatric evaluation".
Client # 1 was admitted on March 29, 2018 and discharged on April 26, 2018. The consent was dated March 29, 2018.
Client # 2 was admitted on January 18, 2018 and discharged on March 1, 2018. The consent was dated January 18, 2018.
Client # 3 was admitted on December 23, 2017 and discharged on February 24, 2018. The consents were dated December 24, 2017 and January 4, 2018.
Client # 4 was admitted on April 12, 2018 and discharged on June 8, 2018. The consent was dated April 12, 2018.
Client # 5 was admitted on May 15, 2018. The consent was dated May 15, 2018.
Client # 6 was admitted on April 21, 2018. The consent was dated April 21, 2018.
Client # 7 was admitted on May 26, 2018. The consent was dated May 26, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director reviewed with all staff the appropriate information to be chosen on insurance consents in order to be in compliance with pa 255.5 code. The insurance consents had also been revised to be in compliance with pa 255.5. Also all clients have been given the revised consent form.
The program director, or program manager, will do an audit on charts monthly to ensure that the consents are in compliance with pa code 255.5. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
The facility failed to document a quarterly inspection of the medication storage area from June 2017 - May 2018.
The findings were reviewed with facility staff and confirmed by the facility director during the licensing process.
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Plan of Correction
Immediately following the inspection the program director contacted the pharmacy to set up monthly inspections. The pharmacy came out to the facility on 06/25/2018 to complete an inspection. The program director will ensure that these inspections continue to occur regularly. The inspections are currently scheduled for the last Monday of every month. |