INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27-28, 2017 by staff from the Division of Drug and Alcohol 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct unannounced fire drills at least monthly and prepare alternate exits to be used during the drills.
The fire drills for the period of May 2016 - May 2017 were reviewed on June 27, 2017. All of the fire drills conducted a the main house for that time period used the front/main exit as the documented exit route. In addition, the stable (building where the counseling offices are) did not have fire drills documented for the months of June, September, October, and December 2016 as well as February & March 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The new fire drill form initiated on July 12 2017 includes alternate routes. Program Director will retrain all staff on the procedures for fire drills including the need for alternate routing and frequency of drills. Program Director will monitor monthly drills to ensure 100% compliance. Action plan completed on July 12 2017. |
709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
The faciltiy failed to document the proposed type of support service on the individualized treatment and rehabilitation plan in five of nine inpatient client records.
Nine inpatient client records were reviewed on June 27 -28, 2017. The individualized treatment and rehabilitation plans documented in client records #1, 3, 4, 5 and 6 did not include documentation of proposed support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plan form in electronic medical record was modified to include type of support services on July 12 2017. Staff was retrained on July 12 2017. Program Director will monitor treatment plans monthly to ensure 100% compliance. |