INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on July 9-10, 2019. Based on the findings of the on-site inspection, Silvermist, LLC was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
|
Observations
The project director failed to have a comprehensive staff development program for agency personnel including policies and procedures for the program on an overall basis.
There was no overall comprehensive staff development program documented for agency personnel at the program.
|
Plan of Correction
The Human Resources Coordinator will develop a Comprehensive policy for Staff Development by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff by Human Resources with a receipt acknowledgement attached that staff will sign off on. Full implementation of the policy will occur by September 15, 2019. Program Director will develop a comprehensive training plan for staff annually in December that is based on identified needs from the individual training plans completed by staff by October 1, 2019. Program Director will submit training plan to Human Resources by December 15th each year. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
|
Observations
The project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and time frames for completion of assessment of staff training needs overall.
There was no facility staff development program for agency personnel including policies and procedures for the program indicating who is responsible and time frames for completion of staff training needs overall documented at the program.
|
Plan of Correction
The project with develop and approve a Comprehensive policy for Staff Development that will included who is responsible and time frames for completion of assessment of staff training needs overall by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached.Program Director will develop a comprehensive training plan for staff annually in December that is based on identified needs from the individual training plans completed by staff by October 1, 2019. Program Director will submit training plan to Human Resources by December 15th each year. HR coordinator will be responsible to ensure the Assessment of staff training needs is completed on time and available. HR coordinator will review staff records annually to ensure compliance. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
|
Observations
The project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an overall plan addressing these staff needs.
There was no comprehensive staff development program for agency personnel including policies and procedures documented for the program indicating who is responsible and the time frames for completion of an overall plan addressing staff needs.
|
Plan of Correction
The program will develop and approve a Comprehensive policy for Staff Development including who is responsible and the time frames for completion of an overall plan addressing staff needs by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached. The Executive Director will be responsible for ensuring a plan to address staff needs is developed for each staff member annually in accordance to the timeframes identified in the policy. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
The project director failed to develop a comprehensive staff development program for agency personnel as a whole to include policies and procedures for the program indicating who is responsible and the time frames for completion and a mechanism to collect feedback on this this completed training.
There was no comprehensive staff development program for agency personnel as a whole to include policies and procedures for the program indicating who is responsible and the time frames for completion and a mechanism to collect feedback on this this completed training documented at the program.
|
Plan of Correction
The program's current policy addresses who is responsible and the time frames for completion. The Director of Human Resources will develop and approve a Comprehensive policy for Staff Development including identification of where the staff feedback will be stored and how it will be utilized to assess overall training completed by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached. Human Resources Coordinator will ensure feedback for all training completed becomes part of the employee record. These records will be reviewed for compliance annually by the Human Resource Coordinator. Director of Human Resources will review completed training and feedback and develop a comprehensive evaluation annually by March 1 of each year. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
|
Observations
The project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan.
There was no comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan documented at the program.
|
Plan of Correction
The program will develop and approve a Comprehensive policy for Staff Development including the time frames for completion of an overall evaluation of the staff development programs, including negative and positive conclusions by September 1, 2019. Director of Human Resources will publish the policy by September 1, 2019. The policy will be shared with all staff with a receipt acknowledgement attached. The Director of Human Resources will be responsible for the completion of the evaluation and will ensure it is completed by March of every year. Overall compliance of completion will be monitored by the VP of Human Resources. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
During a physical site inspection on July 10, 2019, the facility failed to have hot water temperatures that did not exceed 120 degrees Fahrenheit.
The water temperature in the hallway bathroom of the main building had a temperature reading of 130 degrees Fahrenheit.
The water temperature in the downstairs bathroom off the living room in the main building had a temperature reading of 130 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The water temperature was changed in all applicable bathrooms to 120 degrees immediately following the exit interview. The water temperature will remain at 120 degrees o less moving forward. To ensure that this occurs the site maintenance manager will randomly test water temperature each month and will limit staff access to water tank. |
709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
|
Observations
During a Project wide review of the Policy and Procedures, the project failed to include sex and marital status in the Client Rights policy.709.30 (2), and also
the project failed to include documentation of the reasons for removing sections from the record. 709.30 (3).
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The policy and procedures manual will be updated by the program director/project manager to include sex and marital status in section 709.30. Once the policy is updated it will be sent to the CEO for approval. The program director will be responsible to ensure that the new policy is revised and implemented. The new policy will be approved and implemented by 08/15/2019. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
|
Observations
During a review of client records on July 9, 2019, the facility failed to notify clients of all their civil rights in seven out of seven records.
Client #1 was admitted on June 1, 2019 and was current at the time of the inspection. Client #1 was not notified that the project may not discriminate in the provision of services on the basis of color and sex.
Client #2 was admitted on May 12, 2019 and was current at the time of the inspection. Client #2 was not notified that the project may not discriminate in the provision of services on the basis of color and sex.
Client #3 was admitted on May 3, 2019 and was current at the time of the inspection. Client #3 was not notified that the project may not discriminate in the provision of services on the basis of color and sex.
Client #4 was admitted on March 28, 2019 and was discharged on May 8, 2019. Client #4 was not notified that the project may not discriminate in the provision of services on the basis of color and sex.
Client #5 was admitted on December 23, 2018 and was discharged on February 7, 2019. Client #5 was not notified that the project may not discriminate in the provision of services on the basis of color and sex.
Client #6 was admitted on February 8, 2019 and was discharged on April 9, 2019. Client #6 was not notified that the project may not discriminate in the provision of services on the basis of color and sex.
Client #7 was admitted on December 4, 2018 and was discharged on January 28, 2019. Client #7 was not notified that the project may not discriminate in the provision of services on the basis of color and sex.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The PD had contacted the EVP of Corporate Compliance to inform her of the deficiency.
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information.
The Clinical Forms Committee will create a new form to be added to Carelogic for all programs that fall under Pyramid Healthcare.
The form will be updated and approved by the EVP of corporate compliance by 08/15/19. The form update will be shared with all staff with a receipt acknowledgement attached. |
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.
|
Observations
During a review of records on July 9, 2019, the facility failed to provide documentation of client follow-up information.
Client #4 was admitted on March 28, 2019 and was discharged on May 8, 2019. There was no follow-up documentation provided for Client #4.
Client #5 was admitted on December 23, 2018 and was discharged on February 7, 2019. There was no follow-up documentation provided for Client #5.
Client #6 was admitted on February 8, 2019 and was discharged on April 9, 2019. There was no follow-up documentation provided for Client #6.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Program Director met with the clinical the day of the exit interview to discuss the deficit. The Director reminded the staff to complete notes for all follow up call which are to be done 7,30, and 60 days post discharge. The Director will also complete weekly chart audits to ensure that follow up calls are being completed and properly documented. |