INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29-30, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Silver Pines Treatment Center 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(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to provide documentation of supervision by a full-time clinical supervisor for employee # 9.
Employee # 9 was hired on December 17, 2018 and was still in this position at the time of the inspection. It was determined that supervision was not being conducted by a qualified full-time clinical supervisor.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment Center will ensure that a counselor assistant will be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7. This will be rectified by:
Step 1 Administration will pick a qualified candidate to provide supervision.
Step 2 A Counselors was found to be qualified in supervising counselor assistant.
Step 3 This Supervising Counselor will receive training based off of our procedure of documentation.
Step 4 Supervision will occur weekly and documented properly by qualified Counselor.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to provide documentation of annual written training plans for employee #'s 10, 11, 12, 13, 14, 15.
The Department was not provided a documented date of a written individual training plan being developed for employee #10 who was hired on August 5, 2017 and was still in this position at the time of the inspection.
The Department was not provided a documented date of a written individual training plan being developed for employee # 11 who was hired on April 23, 2019 and was still in this position at the time of the inspection.
The Department was not provided a documented date of a written individual training plan being developed for employee # 12 who was hired on April 23, 2019 and was still in this position at the time of the inspection.
The Department was not provided a documented date of a written individual training plan being developed for employee # 13 who was hired on February 15, 2019 and was still in this position at the time of the inspection.
The Department was not provided a documented date of a written individual training plan being developed for employee # 14 who was hired on October 22, 2018 and was still in this position at the time of the inspection.
The Department was not provided a documented date of a written individual training plan being developed for employee # 15 was hired on April 11, 2019 and was still in this position at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment Center will ensure that an individual training plan shall be developed annually for each client based on an employee's skill level with input from both the employee and the supervisor.
Step 1 All department supervisors will be required to complete a training needs assessment plan upon hire, tailored and targeted to the employees specific career and goals.
Step 2 The department supervisors will create a draft training plan based on the training needs assessment.
Step 3 Both the supervisor and employee will discuss the training plan to give equal input for finalizing the treatment plan.
Step 4 The supervisor and the employee will sign the training plan and each get a copy.
Step 5 The training plan will be placed in the employee's personnel files. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to provide documentation that the fire alarm or smoke detector was operative during the fire drill.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment Center will ensure that the residential facility will maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative by:
Step 1 Facility Director and Facility Manager will review and edit policy and procedure to reflect compliant information from 705.10(d)
Step 2 A change to our previous form will be made to add whether the fire alarm or smoke detector was operative.
Step 3 All staff involved will be trained accordingly to the changes made.
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709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(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.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. The facility was/is providing Buprenorphine services without prior approval/licensure from the department.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment center has applied for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
Step 1 Silver Pines has edited our policies and procedures to reflect best practice as laid out by Licensing alert 04-12
Step 2 Silver Pines has submitted all that was required by the Division of Drug and Alcohol Program to get the exception and are awaiting approval.
Step 3 Client that were admitted at the time, will continue to get their medication taper until they are detoxed.
Step 3 In the event that Silver Pines Treatment Center does not receive the buprenorphine exception, the detoxification unit will use non-medical means and comfort medication to help with the detoxification process for opiates.
Step 4 Research would be done to look into other options of detoxification such as Levo-alpha-acetylmethadol (LAAM)- which is a long-acting opioid agonist approved for use as a maintenance treatment for opioid dependence or a slow sustained morphine taper to numb the effects of withdrawal.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to provide documentation of an annual staff performance evaluation for employee # 5. The facility failed to provide copies of reviewed and signed annual staff performance evaluations for employees # 6 and # 7.
Employee # 5 was hired on April 30, 2018 and was still in the position at the time of the inspection. There was no documentation of annual review that would have been due in April 2019.
Employee # 6 was hired on November 13, 2017 and was still in the position at the time of the inspection. There was no documentation the employee reviewed and signed the evaluation.
Employee # 7 was hired on October 2, 2017 and was still in the position at the time of the inspection. There was no documentation the employee reviewed and signed the evaluation.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines treatment center will ensure that DDAP regulation:§ 709.26. is within compliance when completing individual staff performance annual evaluations for all staff members. This will be achieved by the following measures :
Step 1: All staff will be required to complete a self evaluation upon their anniversary date and will then read , review, and sign the document after meeting with their direct supervisor to discuss the outcomes of their performance evaluation
Step 2:Upon completing the evaluation and review with the employee, the supervisor of the employee with ensure that all signatures have been properly placed upon the evaluation form . The supervisor will then make three copies of the evaluation and disperse them as followed:
1 for Human resources
1 for the staff member
1 for the direct supervisor.
Step 3:After all copies have been made, the Human resources department will file the staff evaluation in the appropriate location in the staff members personnel chart.
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709.28 (c) 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.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 2, 3, 4, 5, 6, and 7. Consent for treatment and assignment of benefits form allows information to be released to government and insurances agencies beyond 255.5.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment Center will ensure all clients confidentiality by obtaining an informed consent and voluntary consent from the client for the disclosure of information contained in the client record.
Step 1 Consent for treatment and assignment of benefits form will not allow information to be released to government and insurances agencies beyond 255.5.
Step 2 The clause stated in the previous form will be deleted.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 4.
Client # 4 was admitted on May 19, 2019 and was still an active client at the time of the inspection. A consent to release to an employer signed and dated May 21, 2019 allowed for prognosis of client, discharge summary, discharge plan, brief description of client's progress, and a short statement as to whether the client has relapsed into drug or alcohol use and frequency of such use. The release of the discharge summary and discharge plan exceeded 4 Pa. Code 255.5 (b).
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment Center will ensure all clients confidentiality by obtaining an informed consent and voluntary consent from the client for the disclosure of information contained in the client record.
Step 1 Client consents regarding employers will be revised to declare that only presence in treatment will be disclosed to all employers if a client signs consent for that employer |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to document a completed consent to release information in 7 records, as there were forms that were missing required information. Seven of seven client records reviewed had consent forms that did not document that a copy of the release was offered to the client.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment Center will ensure all client's confidentiality by offering the client a copy of all of their signed consents.
Step 1 All documents will contain a question to accept or deny a copy of consent.
Step 2 Admissions staff will make sure this is filled out properly and provide them with a copy of the consent if they accept.
Step 3 All client charts will be audited within 2 days of client's admission by the Quality Assurance Officer. This will ensure that all clients are being offered and/or given copies of the releases if they accept the offer. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in client record # ' s 1, 2, 3, and 4.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment Center will ensure that all clients acknowledge their rights by:
Step 1 Mandating that each client give written acknowledgment by the client that the client had been made aware of their rights at the time of admission.
Step 2 Clients will then be read these rights with a staff member and sign once again that they have been notified of their rights. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to document a medication inventory that was completed at least quarterly.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment Center will ensure the compliance of Medication control for the following: Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to: What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded. Disinfectants and drugs for external use are stored separately from oral and injectable drugs. Drugs requiring special conditions for storage to insure stability are properly stored. Outdated drugs are removed. Copies of drug-related regulations are available in appropriate areas.
Step 1 We have launched a program that takes electronic inventory of medications in our Electronic Medical Records called KIPU - Medications 2.0.
Step 2 The nursing staff will do a count of medication when it arrives from the pharmacy.
Step 3 The nursing staff will keep record of medication that is destroyed and sent home with client upon discharge. |
709.62(b) LICENSURE Delayed intake procedures
709.62. Intake and admission.
(b) Intake procedures other than initial medical care shall be performed at a time when the immediate physiological effects of drug and alcohol abuse have subsided.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to provide documentation of a client intake that included disclosure to the client the criteria for admission, treatment, completion and discharge in client records #1, 2, and 3.
The facility failed to provide a client orientation in client records #1,2, and 3 that included project policies, hours of operation, fee schedule, and services provided.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment Center will ensure that all intake procedures other than initial medical care shall be performed at a time when the immediate physiological effects of drug and alcohol abuse have subsided by the following:
Step 1 At the time of intake, clients will be assessed on the level of comprehension they have to signing their consents.
Step 2 Form containing Client Rights will be changed to include Silver Pines' policies, hours of operation, fee schedule, services provided, disclosure to the client the criteria for admission, treatment, completion and discharge.
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709.63(a) LICENSURE Client record
709.63. 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:
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to provide documentation of a complete client record to include a drug and alcohol support plan and medication records in one of three client records reviewed.
Client # 3 was admitted on April 30, 2019 and discharged on May 4, 2019. There was no documented drug and alcohol support plan. The medication administration record indicated medication was administered on May 2-4, 2019, however there was no client signature verifying the medication was administered.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment Center will ensure the quality of client records by the following:
Step 1 Client charts will provide documentation of a complete client record to include a drug and alcohol support plan and medication records.
Step 2 Every client chart will have documented drug and alcohol support plan.
Step 3 All medication administration records will indicate medication was administered and include a client signature verifying the medication was administered. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to provide documentation of client #4 ' s intake procedures including disclosure to the client the criteria for admission, treatment, completion and discharge. Client #4 ' s orientation to the project did not include the project policies, hours of operation, fee schedule, and services in the client record.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines Treatment Center will see to it that intake procedures shall include the documentation of disclosure to the client of criteria for admission, treatment, completion and discharge.
Step 1 Admission form "Client Rights" will be revised to include the documentation of disclosure to the client of criteria for admission, treatment, completion and discharge. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to provide written documentation of type and frequency of treatment and rehabilitation services in individual treatment plans in client records # 4, 5, 6, and 7.
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Plan of Correction
Silver Pines treatment center will ensure that all treatment plans are in proper alignment with DDAP regulation 709.52 and will include type and frequency of treatment and rehabilitation services delivered to clients being treated at Silver Pines Treatment Center . This will be achieved through the following measures:
Step 1:A change will be made to the EMR system KIPU to change the treatment plan that is presently utilized to include identification of type and frequency of each service that is being provided to the client on an individual basis
Step 2:Through the individualized treatment planning process the Primary therapist with along with the client will identify the specific type and frequency of services that are being provided, which will then be detailed on the clients individualized treatment plan .Treatment Plan goal will be sure to include specific designation for group, individual, holistic, art therapy, and family therapy related sessions for both type and frequency of each service
Step 3:Treatment plans will then be reviewed by the therapist and signed clinical director to ensure that the type and frequencies are being identified for each individual client and the services being rendered.
Step 4:Client records will be reviewed weekly by the Clinical director, Senior Primary therapist and Primary therapist . If any deficiencies are found the Primary Therapist will be responsible for taking immediate corrective action.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
During a licensing inspection conducted on May 29-30, 2019, the facility failed to provide documentation of complete client records in four of four records reviewed that included information relative to the client ' s involvement with the project.
Client # 4 was admitted on May 19, 2019 and was still active at the time of the inspection. The facility failed to verify in the client record that work done by the client at the project is an integral part of his/her treatment and rehabilitation plan.
Client # 5 was admitted on May 14, 2019 and was still active at the time of the inspection. The facility failed to verify in the client record that work done by the client at the project is an integral part of his/her treatment and rehabilitation plan.
Client # 6 was admitted on May 13, 2019 and was still active at the time of the inspection. The facility failed to verify in the client record that work done by the client at the project is an integral part of his/her treatment and rehabilitation plan.
Client # 7 was admitted on May 13, 2019 and was still active at the time of the inspection. The facility failed to verify in the client record that work done by the client at the project is an integral part of his/her treatment and rehabilitation plan.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Silver Pines treatment center will ensure that DDAP regulation 709.52 is within compliance when utilizing Works as an integral part of their treatment process. This will be achieved by the following measures :
Step 1: A change will be made to the EMR system KIPU to include a specific work related treatment plan or treatment plan objective to be utilized when identifying work as an integral part to the clients treatment, which will include identification of type and frequency of each work duty that is being assigned to the client on an individual basis.
Step 2:Work as treatment will be specifically identified as a part of their therapeutic process on their individualized treatment plan and will include type and frequency of work duties that are being assigned to clients being treated at Silver Pines Treatment Center .
Step 3:Treatment plans will then be reviewed by the therapist and signed clinical director to ensure that work as a treatment modality is included on the treatment plan and that the specific type and frequencies of the duties are being identified for each individual client and the services being rendered.
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