INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against facility advice in two out of three applicable records reviewed.
Client #3 was admitted to the detoxification level of care on November 1, 2025, and discharged against facility advice on November 9, 2025. The facility failed to follow their policy related to calling a client ' s emergency contact within twelve hours when the client leaves against facility advice.
Client #4 was admitted to the detoxification level of care on March 30, 2026, and discharged against facility advice on April 4, 2026. The facility failed to follow their policy related to calling a client ' s emergency contact within twelve hours when the client leaves against facility advice.
This is a repeat citation from the April 4, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were retrained to completing and documenting the call to the client's emergency contact when they leave against facility advice on 4/20/26 and again on 5/7/26.
Moving forward, the Clinical Program Manager (or other leadership) will review contact from any APA during the previous night daily.
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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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the record in three out of fourteen records reviewed.
Client #10 was admitted to the inpatient non-hospital rehabilitation level of care on March 30, 2026, and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent to a pharmacy; however, there is documentation in the client record that verifies that the facility had contact with the pharmacy.
Client #11 was admitted to the inpatient non-hospital rehabilitation level of care on October 24, 2025, and discharged on November 9, 2025. There was no documentation that the facility obtained an informed and voluntary consent to the client ' s employer; however, there is documentation in the client record that the facility sent documentation to the employer on October 27 and November 6, 2025.
Client #13 was admitted to the inpatient non-hospital rehabilitation level of care on January 9, 2026, and discharged on February 2, 2026. There was no documentation that the facility obtained an informed and voluntary consent to a drug and alcohol provider; however, there is documentation in the client record that verifies that the facility developed aftercare appointments with the drug and alcohol provider.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client 10, 11 and 13 were discharged at the time of inspection.
All clinical and nursing staff will be retrained on confidentiality requirements and necessity of obtaining a valid ROI prior to any disclosure of information. This training will take place on 5/20/26 and 5/27/26.
Moving forward, the Executive Director and Clinical Program Manager will conduct random weekly audits to ensure that ROI are present for any individual contacted. Any issues with be addressed with staff immediately and staff will receive real time coaching.
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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
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information disclosed in two out of fourteen records reviewed.
Client #3 was admitted to the inpatient non-hospital detoxification level of care on November 1, 2025, and was discharged on November 9, 2025. The record contained one informed and voluntary consent to release information to a medical provider signed by the client on November 1, 2025, that did not document the specific information to be released.
Client #10 was admitted to the inpatient non-hospital rehabilitation level of care on March 30, 2026, and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a medical provider signed by the client on March 30, 2026, that did not document the specific information to be released.
This is a repeat citation from the April 4, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client 3 and 10 were discharged at the time of inspection.
All clinical and nursing staff will be retrained on the required areas of a ROI, including the information to be disclosed and the purpose of disclosure. They will also be retrained on general confidentiality requirements. This training will take place on 5/20/26 and 5/27/26.
Moving forward, overnight nursing staff with audit all new admissions to ensure ROI are complete and accurate.
Nursing Manager and Clinical Program Manager will do weekly random audits to ensure ROI compliance. Any issues with be addressed with staff immediately and staff will receive real time coaching.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in two out of fourteen records reviewed.
Client #3 was admitted to the inpatient non-hospital detoxification level of care on November 1, 2025, and was discharged on November 9, 2025. The record contained one informed and voluntary consent to release information to a medical provider signed by the client on November 1, 2025, that did not document the purpose of the disclosure.
Client #10 was admitted to the inpatient non-hospital rehabilitation level of care on March 30, 2026, and was still active at the time of the inspection. The record contained an informed and voluntary consent to release information to a medical provider signed by the client on March 30, 2026 that did not document that the purpose of the disclosure.
This is a repeat citation from the April 4, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client 3 and 10 were discharged at the time of inspection.
All clinical and nursing staff will be retrained on the required areas of a ROI, including the information to be disclosed and the purpose of disclosure. They will also be retrained on general confidentiality requirements. This training will take place on 5/20/26 and 5/27/26.
Moving forward, overnight nursing staff with audit all new admissions to ensure ROI are complete and accurate.
Nursing Manager and Clinical Program Manager will do weekly random audits to ensure ROI compliance. Any issues with be addressed with staff immediately and staff will receive real time coaching.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in one out of fourteen records reviewed.
Client #10 was admitted to the inpatient non-hospital rehabilitation level of care on March 30, 2026, and was still active at the time of the inspection. The client was prescribed medication, and the prescription stated that one tablet was to be taken daily. The medication administration records showed that the medication was not given on April 7, 2026. There was no additional documentation indicating a reason why the medication was not given as prescribed.
This is a repeat citation from the April 4, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client 10 has been discharged.
The nurses will be retrained during on documentation of medication administration during their nursing meeting on 5/27/26. This will be reviewed during nursing meetings each month.
Nurses will be expected to review their documentation after each medication passes to ensure all medications are signed out.
The Nurse Manager will perform random weekly audits to ensure compliance.
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