INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 2022, 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of seven personnel records, the facility failed to supervise one applicable counselor assistant with a high school diploma under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients under the close supervision of a lead counselor or a clinical supervisor.
Employee #7 was hired as a counselor assistant on December 26, 2021 and was still in this position at the time of the inspection. Employee #7 did not receive direct observation from December 26, 2021 to March 26, 2022. Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities " . The fully qualified clinical supervisor or counselor is then responsible for weekly supervision notes relating to the counselor assistant. Clear documentation in the weekly notes and in the pertinent client charts must also demonstrate that direct observation is occurring. The notes provided during the licensing process did not provide clear documentation that direct observation was occurring. The documented supervision notes from January 10, 2022, January 24, 2022, February 10, 2022, February 22, 2022, February 28, 2022, March 17, 2022, and March 21, 2022, did not provide that direct observation was occurring.
Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . Supervision is to focus on the development of the counselor assistant ' s clinical skills. Weekly supervision notes must clearly demonstrate that close supervision is occurring. The weekly notes should also provide a reference to the charts that will demonstrate that at least one hour per week of direct observation is being conducted. The documented supervision for March 29, 2022, April 6, 2022, May 7, 2022, and June 27, 2022, identified case reviews occurred but did not clearly demonstrate direct observation was occurring. The facility failed to document any weekly supervision was occurring during the weeks of April 13, 2022 through April 20, 2022; April 20, 2022 through April 27, 2022; April 27 through May 4, 2022; May 11, 2022 through May 18, 2022; May 18, 2022 through May 25, 2022; May 25, 2022 through June 1, 2022; June 8, 2022 through June 15, 2022; June 15, 2022 through June 22, 2022; June 29, 2022 through July 6, 2022; and July 6, 2022 through July 13, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will complete and document one hour of direct clinical supervision weekly to focus on the development of clinical skills. The Clinical Director and Executive Director will review staffing requirements for any promotions or hires to counselor assistant to ensure supervision guidelines are being met.
All supervision documentation will be reviewed by the Regional Quality Manager monthly to ensure supervision requirements are being met. |
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.
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Observations
Based on a physical plant inspection on July 20, 2022, the facility failed to have hot water temperatures that did not exceed 120 degrees Fahrenheit.
The water temperature in all bathrooms of all the buildings had a temperature reading of 130 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance will perform and continue to perform water temperature readings on our monthly facility walkthroughs to ensure that water temperature does not exceed 120 degrees Fahrenheit. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of fourteen client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated signature of the client in three records reviewed.
Client #1 was admitted on July 6, 2022 and was current at the time of the inspection. An informed and voluntary consent dated July 6, 2022, to the insurance company did not include the client's signature.
Client #6 was admitted on March 30, 2022 and was discharged on April 4, 2022. An informed and voluntary consent dated March 31, 2022, to the insurance company did not include the client's signature.
Client #8 was admitted on July 8, 2022 and was current at the time of the inspection. An informed and voluntary consent dated July 8, 2022, to the funding source did not include the client's signature.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Clinical director will re-educate all staff regarding the importance of having a client sign a release of information. Silvermist leadership with monitor "My Alerts" in CareLogic to ensure all releases of information are fully signed. |
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 seven client records, the facility failed to provide individual counseling at least twice weekly in all records reviewed.
This was reviewed with the facility during the licensing process.
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Plan of Correction
By 08/04/2022 the 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. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of seven client records, the facility failed to provide a complete client record with information relative to the client's involvement with the project that included case consultations in accordance with the facility's policy and procedure manual in seven records reviewed. The facility's policy and procedure manual indicate a case consultation is to occur for partial care within seven days of admission and upon discharge.
Client #8 was admitted on July 8, 2022 and was still active at the time of the inspection.
There was not a case consultation documented in the record within seven days of admission.
Client # 9 was admitted on July 15, 2022 and was still active at the time of the inspection.
There was not a case consultation documented in the record within seven days of admission.
Client # 10 was admitted on July 14, 2022 and was still active at the time of the inspection.
There was not a case consultation documented in the record within seven days of admission.
Client # 11 was admitted on July 12, 2022 and was still active at the time of the inspection. There was not a case consultation documented in the record within seven days of admission.
Client # 12 was admitted on December 30, 2021 and was discharged on January 6, 2022.
There was not a case consultation documented in the record within seven days of admission or at discharge.
Client # 13 was admitted on May 19, 2022 and was discharged on May 28, 2022.
There was not a case consultation documented in the record within seven days of admission.
Client # 14 was admitted on May 10, 2022 and was discharged on May 14, 2022.
There was not a case consultation documented in the record within seven days of admission.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will re-educate clinical team on the requirement to have a case consult within 7 days of admission for both partial level of care and inpatient level of care.
The Regional Quality Manager will review chart audits on a monthly basis to ensure case consults are being completed within required timeframe.
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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 a review of three applicable client records, the facility failed to provide a complete client record on an individual relative to the client's involvement with the project that included follow up information in accordance with the facility's policy and procedure manual. The facility's policy and procedure manual indicated the facility is to follow-up on the client within seven days of discharge.
Client # 12 was admitted on December 30, 2021 and was discharged on January 6, 2022. There was no documented follow-up information in the client record at the time of the inspection.
Client # 13 was admitted on May 19, 2022 and was discharged on May 28, 2022. There was no documented follow-up information in the client record at the time of the inspection.
Client # 14 was admitted on May 10, 2022 and was discharged on May 14, 2022. There was no documented follow-up information in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from an inspection conducted on May 27, 2021.
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Plan of Correction
Clinical Director will re-educate the clinical team around completing a follow-up call to clients within 7 days of their discharge. These calls will be documented in the client's chart. The Regional
Quality Manager will review chart audits on a monthly basis to ensure 7-day follow-up calls are being completed within required timeframe. |
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 a review of seven client records, the facility failed to provide a complete client record with information relative to the client's involvement with the project that included case consultations in accordance with the facility's policy and procedure manual in seven records reviewed. The facility's policy and procedure manual indicate a case consultation is to occur for partial care within seven days of admission and upon discharge.
Client #1 was admitted on July 6, 2022 and was still active at the time of the inspection.
There was not a case consultation documented in the record within seven days of admission.
Client # 2 was admitted on June 23, 2022 and was still active at the time of the inspection.
There was not a case consultation documented in the record within seven days of admission.
Client # 3 was admitted on July 9, 2022 and was still active at the time of the inspection.
There was not a case consultation documented in the record within seven days of admission.
Client # 4 was admitted on June 23, 2022 and was still active at the time of the inspection. There was not a case consultation documented in the record within seven days of admission.
Client # 5 was admitted on June 1, 2022 and was discharged on July 1, 2022.
There was not a case consultation documented in the record within seven days of admission or discharge.
Client # 6 was admitted on March 30, 2022 and was discharged on April 4, 2022.
There was not a case consultation documented in the record within seven days of admission.
Client # 7 was admitted on February 14, 2022 and was discharged on February 22, 2022.
There was not a case consultation documented in the record within seven days of admission.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from the licensing inspection that took place on May 27, 2021.
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Plan of Correction
Clinical director will re-educate clinicians on the requirement to have a case consult within 7 days of admission for both partial level of care and inpatient level of care. The Regional
Quality Manager will review chart audits on a monthly basis to ensure case consults are being completed within required timeframe. |
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 a review of three applicable client records, the facility failed to provide a complete client record on an individual relative to the client's involvement with the project that included follow up information in accordance with the facility's policy and procedure manual. The facility's policy and procedure manual indicated the facility is to follow-up on the client within seven days of discharge.
Client # 5 was admitted on June 1, 2022 and was discharged on July 1, 2022. There was no documented follow-up information in the client record at the time of the inspection.
Client # 6 was admitted on March 30, 2022 and was discharged on April 4, 2022. There was no documented follow-up information in the client record at the time of the inspection.
Client # 7 was admitted on February 14, 2022 and was discharged on February 22, 2022. There was no documented follow-up information in the client record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 27, 2021 annual inspection and the July 9-10, 2019 annual inspection.
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Plan of Correction
Clinical Director will re-educate the clinical team around completing a follow-up call to clients within 7 days of their discharge. These calls will be documented in the client's chart.
The Regional Quality Manager will review chart audits on a monthly basis to ensure 7-day follow-up calls are being completed within required timeframe. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing and documenting follow-up information for the inpatient records was submitted and approved by the Department for the May 27, 2021 and July 9-10, 2019 annual licensing inspections. Completing and documenting follow-up information was again found to be a deficiency in the July 20, 2022 licensing inspection.
A plan of correction for completing and documenting follow-up information for the partial hospitalization records was submitted and approved by the Department for the May 27, 2021 annual licensing inspection. Completing and documenting follow-up information was again found to be a deficiency in the July 20, 2022 licensing inspection.
A plan of correction for providing case consultations in accordance with the facility's policy and procedure manual was submitted and approved by the Department for the May 27, 2021 annual licensing inspection. Providing case consultations in accordance with the facility's policy and procedure manual was again found to be a deficiency in the July 20, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Silvermist has not had consistent leadership which has impacted the treatment team's ability to monitor the plans of correction on an ongoing basis. A Regional Quality Manager has been assigned to Silvermist starting in April 2022 to assist Silvermist in monitoring ongoing chart audits to ensure adherence to plans of correction. Key Performance Indicators (KPIs) have been developed to assist with this task and are reviewed with Silvermist's Leadership Team on a monthly basis. |