INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted July 7, 2022, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Silvermist LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of three client charts, the facility failed to review and update the treatment and rehabilitation plans every 30 days in two client records.
Client #1 was admitted to PHP on 5/30/2022 and is a current client. The comprehensive treatment plan was completed on 6/3/2022. A treatment plan update was not located for 7/3/2022. There was no 30 day treatment plan update in the client chart as of 7/7/2022.
Client #2 was admitted to inpatient rehabilitation and treatment on 5/26/2022. The client was then admitted to PHP on 6/25/2022 and is a current client. The treatment plan was completed on 5/27/2022. There was no 30 day treatment plan update in the client chart as of 7/7/2022.
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Plan of Correction
By 08.04.2022, Clinical Director will re-educate clinical staff on the following areas:
Treatment plan reviews are to be completed every 14 days at a residential level of care
Treatment plans must be updated when individual transitions to partial hospitalization level of care and need to reflect the transition from 3.5 to 2.5 including the change to two individual sessions per week.
Each therapist will document the next review date on their outlook calendar and desk calendar/appointment book
Clinical Director and Executive Director will complete weekly chart reviews and monitor Carelogic alerts to ensure clients are receiving counseling on a regular basis per their individualized treatment plan and level of care.
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709.82(d) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
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Observations
Based on a review of three client charts, the facility failed to provide counseling on a regular basis.
Client #1 was admitted to PHP on 5/30/2022 and is a current client. The comprehensive treatment plan dated 6/3/2022 indicates that the client is to receive weekly individual counseling. Progress notes show that this service was provided 5/31/22, 6/17/22, and 7/1/22. There is no record of individual counseling during the weeks of 6/7/22 or 6/20/22.
Client #2 was admitted to inpatient rehabilitation and treatment on 5/26/2022. The client was then admitted to PHP on 6/25/2022 and is a current client. The treatment plan dated 5/27/2022 indicates that the client is to receive weekly individual counseling. Progress notes show that this service was provided on 5/27/22, 6/2/22, 6/9/22, 6/11/22, 6/22/22, 6/25/22, and 7/2/22. There is no record of individual counseling during the week of 6/16/22.
Client #3 was admitted to inpatient rehabilitation and treatment on 6/6/2022. The client was then admitted to PHP on 7/6/2022 and is a current client. The treatment plan dated 6/23/2022 indicates that the client is to receive weekly individual counseling. Progress notes show that this service was provided on 6/9/22, 6/15/22 and 6/23/22. There is no record of individual counseling during the week of 6/30/22.
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Plan of Correction
By 08.04.2022, Clinical Director will re-educate clinical staff on reflecting the amount of group, individual, psychiatric services in the treatment plan and ensure that these services take place/align with what is outlined on the individual treatment plan
CD/ED will audit charts on Monday of each week; send reminders via e-mail for any treatment plan that is due for update of that same week.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of three client charts, the facility failed to provide individual counseling at least twice weekly.
Client #1 was admitted to PHP on 5/30/2022 and is a current client. The comprehensive treatment plan dated 6/3/2022 indicates that the client is to receive weekly individual counseling. Progress notes show that this service was provided 5/31/22, 6/17/22, and 7/1/22. The client was not provided individual counseling at least twice a week.
Client #2 was admitted to inpatient rehabilitation and treatment on 5/26/2022. The client was then admitted to PHP on 6/25/2022 and is a current client. The treatment plan dated 5/27/2022 indicates that the client is to receive weekly individual counseling. Progress notes show that this service was provided on 6/25/22 and 7/2/22. The client was not provided individual counseling at least twice a week.
Client #3 was admitted to inpatient rehabilitation and treatment on 6/6/2022. The client was then admitted to PHP on 7/6/2022 and is a current client. The treatment plan dated 6/23/2022 indicates that the client is to receive weekly individual counseling. The treatment plan was not updated to reflect individual counseling twice a week and the client was not provided individual counseling at least twice a week.
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Plan of Correction
By 08.04.2022, Clinical Director will re-educate clinical staff on reflecting the amount of group, individual, psychiatric services in the treatment plan and ensure that these services take place/align with what is outlined on the individual treatment plan. CD will re-educate clinical staff that PHP clients are to receive individual counseling at least twice weekly.
CD/ED will complete weekly chart reviews and monitor Carelogic alerts to ensure clients are receiving counseling on a regular basis per their individualized treatment plan and level of care. |