INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on April 15, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Silver Linings USA Limited Liability Company 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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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to include documentation of preliminary treatment and rehabilitation plans during intake in three of seven outpatient records reviewed.Client #8 was admitted on November 30, 2020 and was active at the time of inspection. There was no documentation of a preliminary treatment plan completed during the intake process. Client #9 was admitted on December 14, 2020 and was active at the time of inspection. There was no documentation of a preliminary treatment plan completed during the intake process. Client #10 was admitted on December 18, 2020 and was active at the time of inspection. There was no documentation of a preliminary treatment plan completed during the intake process. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
In regards to no documentation of a preliminary treatment plan completed during the intake process for clients #8, #9, and #10, Silver Linings USA Limited Liability Company has implemented the following course of actions to ensure compliance for all clients moving forward.
Clinical Supervisor educated staff during clinical meeting on 4/26/2021 on the importance of developing a preliminary treatment plan during the intake process that includes short and long-term goals for treatment as formulated by both staff and client, type and frequency of services, date to see on-site doctor if necessary, and interest in medical assisted treatment. Additionally, clinical supervisor spoke with EHR representative on 4/26/21 to establish tracking of treatment plan being completed during the intake process. Clinical Director will be easily able to track completed/incomplete documents, and if it is incomplete Clinical Director will advise clinical staff of the need to complete in writing. If a clinical staff member is unable to meet these expectations, a plan of action will be developed to ensure compliance with 709.91. Intake and admission.
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