INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 11, 2021 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:
|
Plan of Correction
|
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
|
Observations
During a physical site inspection on May 11, 2021, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
The trash dumpster was overflowing with trash and the lid could not be put down.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Moving forward the Property Manager will ensure that boxes are properly broken down to make proper space in the dumpster. Property Manager will monitor trash to ensure that it is not overflowing. |
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.
|
Observations
Based on a review of four personnel records on May 11, 2021, the facility failed to complete an annual written individual staff performance evaluation within the specified time frame in one record reviewed.
Employee #2 was hired as a counselor on March 4, 2020 and should have had an annual performance evaluation no later than March 4, 2021. The was no documentation of a performance evaluation in their personnel record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director of Quality Assurance and HR Administrator will monitor and audit employee evaluations on a quarterly and monthly basis. Staff will be reminded as need to complete their evaluations in a timely manner.
Employee #2 will receive her evaluation on 6/15/21. |
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.
|
Observations
Based on a review of twelve client records on May 11, 2021, 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 three records reviewed.
Client #1 was admitted on February 12, 2021 and discharged on March 21, 2021. A consent to release information to a third-party payor dated February 12, 2021 included patient history, emergency contact information and also court services/legal purposes.
Client #5 was admitted on December 2, 2020 and discharged on December 10, 2020. A consent to release information to a third-party payor dated December 2, 2020 included patient history, emergency contact information and also court services/legal purposes.
Client #10 was admitted on November 21, 2020 and discharged on December 26,2020. A consent to release information to a third-party payor dated November 21, 2021 included patient history, emergency contact information and also court services/legal purposes.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Director of Quality Assurance and Executive Director will have a training on proper use of consents on 6/22/21. All staff who are responsible for signing consents with clients will be in attendance.
Director of Quality Assurance will audit consents on a weekly basis. Based on these audits staff will be followed up with individually. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
|
Observations
Based on a review of patient records on May 11, 2021, the narcotic treatment program failed to verify that the individual had reached eighteen years of age in two out of four applicable patient records reviewed.
Client # 1 was admitted on May 7, 2021 and was still current at the time of the inspection. The program failed to verify that the individual had reached eighteen years of age.
Client # 13 was admitted on April 16, 2021 and was still current at the time of the inspection. The program failed to verify that the individual had reached eighteen years of age.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
Effective 6/28/21, all ID will be uploaded to the EMR upon intake by the Care Coordinator. If client does not have an ID, the Care Coordinator will notify the Care Manager. The Care Manager will work the patient to retrieve proper identification.
Director of Quality Assurance will audit on a weekly basis and follow up with necessary staff for further training.
Client #1 is no longer in services.
Client #13 is no longer in services. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
|
Observations
Based on a review of 14 patient records on May 11, 2021, the narcotic treatment program failed to verify the individual's identity, including name, address, date of birth, and other identifying data in two out of four applicable patient records reviewed.
Client # 1 was admitted on May 7, 2021 and was still active at the time of the inspection. The program failed to verify the individual's identity including name, address, and date of birth.
Client # 13 was admitted on April 16, 2021 and was still active at the time of the inspection. The program failed to verify the individual's identity including name, address, and date of birth.
These findings were reviewed with program staff during the licensing process.
This is a repeat citation from the licensing inspection dated September 1, 2020.
|
Plan of Correction
Prior to admission, the client's name, address, date of birth and emergency contact will be documented in the client's chart. When a client admits to the program the facility will obtain their ID to verify name, address, and date of birth. During intake, the Care Manager or nursing staff doing the intake will confirm that the emergency contact information on file is correct. Before administration of medication, staff will review patient's ID as well as their emergency contact.
Director of Quality Assurance will audit on a weekly basis and follow up with necessary staff for further training.
Client #1 is no longer in services
Client #13 is no longer in services |
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.
|
Observations
Based on the review of client records on May 11, 2021, the facility failed to document type and frequency of treatment and rehabilitation services in three out of seven applicable records reviewed.
Client #8 was admitted on April 26, 2021 and was still active at the time of the inspection. The comprehensive treatment plan dated April 29, 2021 did not have type and frequency of treatment and rehabilitation services documented.
Client #12 was admitted on March 13, 2021 and was still active at the time of the inspection. The comprehensive treatment plan dated March 23, 2021 did not have type and frequency of treatment and rehabilitation services documented.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Executive Director will meet with the Clinical team by 6/25/21. During this time he will review treatment plans, treatment plan expectations and guidelines.
Director of Quality Assurance will weekly audit treatment plans to ensure that treatment plans are completed and meet required expectations. Executive Director and Director of Quality Assurance will follow up with necessary staff.
Client #8 is no longer in services.
Client #12 is no longer in services. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
|
Observations
Based on the review of client records on May 11, 2021, the facility failed to document support services in the individual treatment and rehabilitation plan in three out of seven applicable records reviewed.
Client #8 was admitted on April 26, 2021 and was still active at the time of the inspection. There was no documentation of proposed type of support services in the individual treatment and rehabilitation plan.
Client #9 was admitted on April 23, 2021 and was still active at the time of the inspection. There was no documentation of proposed type of support services in the individual treatment and rehabilitation plan.
Client #11 was admitted on February 12, 2021 and was discharged on March 21, 2021. There was no documentation of proposed type of support services in the individual treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Executive Director and Director of Quality Assurance will conduct a training with Clinical staff on 6/28/21. During this training, regulation 709.52 will be reviewed. Executive Director will discuss documenting support services within the treatment plan. After this training staff will be knowledgable of the necessary documentation of a treatment plan.
Director of Quality Assurance will weekly audit treatment plans to ensure that support services are documented in treatment plans . Executive Director and Director of Quality Assurance will follow up with necessary staff.
Client #8 is no longer in services.
Client #9 is no longer in services.
Client #11 is no longer in services. |
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.
|
Observations
Based on a review of client records on May 11, 2021, the facility failed to include case consultation notes in one out of three applicable records reviewed.
Client #10 was admitted on November 21, 2020 and was discharged on December 26, 2020. There was no documentation of case consultation notes in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Executive Director will meet with the Clinical Team on 6/25/21. During this time he will review expectations and time frames around completion of case consultations.
Moving forward, Director of Quality Assurance will audit case consultations on a weekly basis. Executive Director and Director of Quality Assurance will follow up with staff as needed.
Client #10 is no longer in services. |