INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 4, 2025, 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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709.28 (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 client record in three out of ten records reviewed.
Client #1 was admitted to the inpatient non-hospital detoxification level of care on April 3, 2025 and is still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent to a laboratory; however, there is documentation in the client record that the facility sent a urine sample for testing on April 3, 2025.
Client #4 was admitted to the inpatient non-hospital detoxification level of care on July 31, 2024 and then discharged to the inpatient non-hospital rehabilitation level of care on August 7, 2024 and discharged on September 4, 2024. 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.
Client #5 was admitted to the inpatient non-hospital detoxification level of care on August 10, 2024 and then discharged to the inpatient non-hospital rehabilitation level of care on August 18, 2024 and discharged on September 4, 2024. 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 finding were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 is no longer in services.
Staff will be retrained on the completion of consents to release information. Staff were trained that consents need to be completed and signed before reaching out to any entity. Staff was trained/will be trained in groups on the following dates: 4/11, 4/22 and 4/24. During this training, they were reminded of appropriate disclosure, areas of a consent, and methods of self-audit to ensure compliance.
The Director of Quality Assurance will audit consents on a monthly basis moving forward.
The Clinical Director will do quarterly audits to ensure compliance.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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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 name of the person, agency or organization to whom disclosure is made in one out of ten records reviewed.
Client #3 was admitted to the inpatient non-hospital detoxification level of care on March 15, 2025 and was discharged to the non-hospital rehabilitation level of care on March 20, 2025 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information signed by the client on March 15, 2025, that did not identify the name of the person, agency or organization.
This is a repeat citation from the March 20, 2024 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #3 has since been discharged.
Staff was trained/will be trained in groups on the following dates: 4/11, 4/22 and 4/24. During this training, they were reminded of appropriate disclosure, areas of a consent, and methods of self-audit to ensure compliance.
The Director of Quality Assurance will audit consents on a monthly basis moving forward.
The Clinical Director will do quarterly audits to ensure compliance.
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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 ten records reviewed.
Client #1 was admitted to the inpatient non-hospital detoxification level of care on April 3, 2025 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information form to a medical provider signed by the client on April 3, 2025, that did not document the specific information to be disclosed.
Client #3 was admitted to the inpatient non-hospital detoxification level of care on March 15, 2025 and was discharged to the inpatient non-hospital rehabilitation level of care on March 20, 2025 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information form to a medical provider signed by the client on March 15, 2025, that did not document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 has since discharged the program.
Client #3 has since discharged the program.
Staff was trained/will be trained in groups on the following dates: 4/11, 4/22 and 4/24. During this training, they were reminded of appropriate disclosure, areas of a consent, and methods of self-audit to ensure compliance.
The Director of Quality Assurance will audit consents on a monthly basis moving forward.
The Clinical Director will do quarterly audits to ensure compliance.
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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 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 ten records reviewed.
Client #3 was admitted to the inpatient non-hospital detoxification level of care on March 15, 2025 and was discharged to the inpatient non-hospital rehabilitation level of care on March 20, 2025 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information form to a medical provider signed by the client on March 15, 2025, that did not document the purpose of the disclosure.
Client #14 was admitted to the inpatient non-hospital rehabilitation level of care on November 6, 2024 and discharged on December 4, 2024. The record contained an informed and voluntary consent to release information form to a family member/emergency contact signed by the client on November 21, 2024, that did not document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #3 has since been discharged.
Staff was trained/will be trained in groups on the following dates: 4/11, 4/22 and 4/24. During this training, they were reminded of appropriate disclosure, areas of a consent, and methods of self-audit to ensure compliance.
The Director of Quality Assurance will audit consents on a monthly basis moving forward.
The Clinical Director will do quarterly audits to ensure compliance.
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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
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in three out of ten client records reviewed.
Client #3 was admitted to the inpatient non-hospital detoxification level of care on March 15, 2025 and discharged to the inpatient non-hospital rehabilitation level of care on March 20, 2025 and was still active at the time of the inspection. There was no documentation that a copy of an informed and voluntary consent to release information form for a medical provider dated March 15, 2025, was offered to the client.
Client #5 was admitted to the inpatient non-hospital detoxification level of care on August 10, 2024 and discharged to the inpatient non-hospital rehabilitation level of care on August 18, 2024 and discharged on September 4, 2024. There was no documentation that a copy of two informed and voluntary consents to release information forms for medical providers dated August 10, 2024, and two informed and voluntary consents to release information forms for drug and alcohol providers dated August 28, 2024, and August 30, 2024, were offered to the client.
Client #13 was admitted to the inpatient non-hospital rehabilitation level of care on May 13, 2024 and discharged on May 16, 2024. There was no documentation that a copy of an informed and voluntary consent to release information form for a medical provider dated May 13, 2024, was offered to the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
CLient #3 has since discharged the program.
Staff was trained/will be trained in groups on the following dates: 4/11, 4/22 and 4/24. During this training, they were reminded of appropriate disclosure, areas of a consent, and methods of self-audit to ensure compliance.
The Director of Quality Assurance will audit consents on a monthly basis moving forward.
The Clinical Director will do quarterly audits to ensure compliance.
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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 two out of ten client records.
Client #5 was admitted to the inpatient non-hospital detoxification level of care on August 10, 2024 and discharged to the inpatient non-hospital rehabilitation level of care on August 18, 2024 and then discharged on September 4, 2024. The client was prescribed a 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 August 20, 22 and 25, 2024. There was no additional documentation indicating a reason why the medication was not given as prescribed.
Client #7 was admitted to the inpatient non-hospital detoxification level of care on March 18, 2025 and then discharged to the inpatient non-hospital rehabilitation level of care on March 23, 2025 and was still active at the time of the inspection. The client was prescribed a medication, and the prescription stated that one tablet was to be taken daily. The medication administration record showed that the medication was not given on March 22, 2025. There was no additional documentation indicating a reason why the medication was not given as prescribed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #7 has been discharged.
The nursing team will be retrained to the documentation of medication in the MAR on 4/22 and 4/24. The nursing team was reminded to self-audit at the end of every shift to ensure ongoing compliance.
Moving forward, the Nurse Manager will audit MARs on a weekly basis.
The Director of Quality Assurance will audit MARs on a monthly basis.
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