INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 11, 2026, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all employees received the minimum of at least 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment in one of three records.
Staff #6 was hired as a counselor on July 22, 2024 and still employed at time of inspection. Staff #6 was due to have the communicable disease trainings no later than July 22, 2025. The HIV/AIDS training was completed on November 7, 2025 and TB/STD was completed on May 5, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ED, Clinical Supervisor, and BHT Manager will track DDAP deadlines during new hire training and through monthly reporting sent to staff to ensure timely completion of all DDAP trainings.
Weekly Relias (training) report sent to site for tracking progress of all trainings. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a review of the facilities physical plant, the facility failed to ensure that cold foods were kept at or below 40 degrees Fahrenheit and frozen foods were kept at or below 0 degrees Fahrenheit.
One refrigerator located in the basement had a facility thermometer which read 43 degrees Fahrenheit. The freezer attached to this refrigerator also had a facility thermometer which read 10 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance team immediately adjusted temperature settings on both refrigerator and freezer unit where these findings took place. Maintenance team ensured both units were back in compliance with temperature guidelines.
Dietary team re-trained by ED on fridge/freezer temperature standards and ensuring thermometers are in range of food safety protocols.
Kitchen Supervisor and Kitchen lead will check temperature logs daily to ensure refrigerator and freezer temperatures remain within regulatory standards. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of client records, the facility failed to inform the Department of an unusual incident within the required three days.
The facility had unusual incidents occur on June 21, 2025, July 26, 2025, August 14, 2025, September 6, 2025, October 3, 2025, April 4, 2026, and April 6, 2026, all which involved fire, police, or ambulance on site. The facility has not submitted written unusual incident reports to the Department at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ED reviewed all missed incidents and submitted outstanding reports to DDAP.
ED retrained Clinical Supervisor and BHT Manager on alerting DDAP in the event of fire, police, or EMS come on-site for any reason.
ED will audit each Unusual Event to ensure DDAP is notified if police, fire, or ambulance arrives on-site for any reason. |
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 client records, the facility failed to complete treatment plan updates according to the facilities policy and procedure in six of seven partial hospitalization client records.
According to agency policy and procedures, treatment plan updates are to be completed every 14 days. The recommended length of treatment for the partial hospitalization program is 21 days.
Client #8 was admitted to partial hospitalization level of care January 5, 2026 and discharged March 3, 2026. A treatment plan was completed on January 29, 2026 and an update was due by February 12, 2026 but not completed until February 16, 2026.
Client #9 was admitted to partial hospitalization level of care March 18, 2026 and discharged April 29, 2026. A treatment plan was completed on March 19, 2026 and an update was due by April 2, 2026 but not completed until April 3, 2026.
Client #10 was admitted to partial hospitalization level of care August 18, 2025 and discharged September 5, 2025. A treatment plan was completed on August 20, 2025 and an update was due by September 3, 2025 but not completed until September 5, 2025.
Client #12 was admitted to partial hospitalization level of care March 11, 2026 and discharged May 10, 2026. A treatment plan was completed on April 24, 2026 and an update was due by May 8, 2026 but not completed prior to discharge.
Client #13 was admitted to partial hospitalization level of care March 26, 2026 and still a current client. A treatment plan was completed on April 9, 2026 and an update was due by April 23, 2026 but not completed until April 27, 2026.
Client #14 was admitted to partial hospitalization level of care April 16, 2026 and still a current client. A treatment plan was completed on April 16, 2026 and an update was due by April 30, 2026 but not completed until May 6, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor reviewed all PHP charts and retrained clinical team to the new standard of PHP treatment plans needing updated every 30 days.
Clinical Supervisor will send out weekly census reports to include treatment plan due dates to all therapists. Clinical Supervisor will audit PHP charts weekly to ensure timely treatment plan submissions. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in two of two applicable records.
The facility's policy and procedure manual states the client ' s emergency contact will be notified within 12 hours of the client ' s decision to leave against facility advice.
Client #3 was admitted to residential level of care September 19, 2025 and discharged October 14, 2025. There was a consent for the emergency contact in the client ' s record, but no documented attempt to contact emergency contact.
Client #4 was admitted to residential level of care November 16, 2025 and discharged December 5, 2025. There was a consent for the emergency contact in the client ' s record, but no documented attempt to contact emergency contact.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ED reviewed AFA discharge procedures with BHT Manager and Clinical Supervisor.
ED, BHT Manager or Clinical Supervisor will meet with client prior to AFA discharge to ensure emergency contact is notified. If leadership is not on-site (after hours, weekends), BHT staff will ensure a phone call with leadership is made and emergency contact is notified.
A mandatory AFA Discharge Checklist has been implemented and must be completed prior to finalizing any AFA discharge.
This checklist includes:
Verification of signed consent for emergency contact
Documentation of the attempt(s) to notify the emergency contact
Date, time, method, and outcome of notification.
In order to monitor compliance with our plan of correction, the Executive Director will review the AFA Discharge Checklist prior to discharge. Executive Director will provide updates to the Regional Director bi-weekly to ensure compliance with plans of correction. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records, the facility failed to complete initial treatment plans according to the agency policy and procedure timeframe in three of seven residential records.
According to agency policy and procedures, the comprehensive treatment plan is completed within 72 hours of admission.
Client #3 was admitted to residential level of care September 19, 2025 and discharged October 14, 2025. The comprehensive treatment plan was due by September 22, 2025 but not completed until September 27, 2025.
Client #6 was admitted to residential level of care September 10, 2025 and discharged October 24, 2025. The comprehensive treatment plan was due by September 13, 2025 but not completed until September 16, 2025.
Client #7 was admitted to residential level of care April 7, 2026 and still a current client. The comprehensive treatment plan was due by April 10, 2026 but not completed until April 11, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor did an audit on all current charts. Clinical Supervisor retrained therapists on 72 hour timeframe for all initial treatment plans per facility regulations.
Clinical Supervisor will audit charts weekly. Daily census review includes treatment plan due dates. Clinical Supervisor will be available to assist to meet timelines if/when therapist is off. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to complete treatment plan updates according to the facilities policy and procedure in five of six residential client records.
According to agency policy and procedures, treatment plan updates are to be completed every 14 days.
Client #2 was admitted to residential level of care April 13, 2026 and discharged May 5, 2026. A treatment plan was completed on April 15, 2026 and an update was due by April 29, 2026 but not completed prior to discharge.
Client #3 was admitted to residential level of care September 19, 2025 and discharged October 14, 2025. A treatment plan was completed on September 27, 2025 and an update was due by October 11, 2025 but not completed prior to discharge.
Client #4 was admitted to residential level of care November 16, 2025 and discharged December 5, 2025. A treatment plan was completed on November 18, 2025 and an update was due by December 2, 2025 but not completed until December 3, 2025.
Client #5 was admitted to residential level of care January 31, 2026 and discharged March 2, 2026. A treatment plan was completed on February 2, 2026 and an update was due by February 16, 2026 but not completed until February 17, 2026.
Client #6 was admitted to residential level of care September 10, 2025 and discharged October 24, 2025. A treatment plan was completed on September 26, 2025 and an update was due by October 10, 2025 but not completed until October 15, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor reviewed all current residential charts. Clinical Supervisor retrained therapists on residential treatment plan update timeline of 14 days.
Clinical Supervisor will complete weekly chart audits. Weekly census report to include treatment plan due dates, sent to all therapists. |