INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6-7, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Silver Pines 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
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the supervision of counselor assistant by full-time clinical supervisor for staff # 6.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A full time Clinical Supervisor will provide:
Weekly one on one supervisory meetings during this 30-week period
Documentation of all supervisory meetings
A written semiannual performance evaluation will be given to the counselor assistant based upon measurable performance standards
The counselor assistant will remain in assistant status during the required supervised period with the intent to achieve a satisfactory rating from the Clinical Supervisor
All client related therapy by the Counselor Assistant is closely observed, monitored, supervised, reviewed and documented weekly by the Clinical Supervisor
Any additional counselor assistants will be supervised by a full time Clinical Supervisor
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document close supervision for the first 6 months of employment for client #6.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Weekly individual supervision of counselor assistants will occur when and if the counselor assistant position is filled. Each individual supervisory meeting will be documented with time, date and the clinical content reviewed and all notes will be documented and filed appropriately.
All clinical staff, including Primary Therapists participate in one-on-one supervision on a weekly basis with the Clinical Director and all clinical supervision documentation records for PT's are filed securely.
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
During an onsite inspection on June 7-8, 2018, the facility failed to provide an overall training plan to include an assessment, feedback, evaluation, training needs for the 2018 training year. The facilities training year is January 2018 through December 2018.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The 2018 staff / facilities development program is current with all required components: assessment, evaluation and individual staff development plans. The staff / facilities development training plan is mapped out according to DDAP training requirements including the following topic areas:
Assessment
Addictions 101
Confidentiality
Practical Application of Confidentiality Laws and Regulations
Case Management Overview
Screening & Assessment
ASAM Training, current edition
Coordination of Services
Addictions 101
Confidentiality
Practical Application of Confidentiality Laws and Regulations
Case Management Overview
ASAM Training, current edition*
All performance development plans and the facility training plan are developed by the Clinical Director and held electronically.
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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.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the trash was stored in containers to prevent the penetration of insects and rodents.
The dumpsters outside the facility in front of the upper parking lot was overflowing and did not allow for the lid to be securely closed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All trash is stored in its appropriate containers and closed tightly to ensure there are no penetration of insects and rodents.
The Facility Director is responsible to check the trash containers daily to ensure all are closed tightly and remain insect and rodent free.
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705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure the safety and well-being of clients, staff, and visitors as evidenced by the following:
Silverware was left out on the counter in open containers instead of being in an enclosed area or covered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All food service items and areas are cleaned several times throughout each day including cleaning all drinking, eating and food preparation utensils and all eating and preparation areas. All eating and related silverware and other eating accessories are kept in an enclosed area and/or covered.
The Food Service Director is responsible for all onsite food preparation, cleaning all drinking, eating and food preparation utensils and all eating and preparation areas. The Food Service Director ensures the safety and well-being of clients, staff and visitors.
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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 review of 7 clients records, the facility failed to secure confidentiality in 7 of 7 client records by disclosing information beyond the scope of Pa. Code 255.5.
A Consent for Release of Confidential information family/other personal Relationship states; "the recipient of the information (my) [sic] re-disclose the information and it may no longer be protected by the HIPAA Privacy Law".
Consent to Disclose Information states; "To collaborate with persons involved in the legal system" and " To facilitate supportive activity with employer.
Consent to release forms also have a check box to "obtain from" listed.
A consent to release of medical information states "to disclose any and all written information".
Client #1 was admitted on 05/24/18 and was an active client at the time of the inspection.
Client #2 was admitted on 05/09/18 and was an active client at the time of the inspection.
Client #3 was admitted on 04/30/18 and was an active client at the time of the inspection.
Client #4 was admitted on 05/17/18 and was an active client at the time of the inspection.
Client #5 was admitted on 01/12/18 and was discharged on 02/09/18.
Client #6 was admitted on 10/04/17 and was discharged on 10/31/17.
Client #7 was admitted on 02/24/18 and was discharged on 03/09/18.
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Plan of Correction
Step 1: Upon Admissions through the responsibility of the Admissions/Intake Specialist, informed and voluntary consents are received from the client for disclosure of information.
Valid consent forms are formatted to capture all the required elements to include:
Name of the individual
Name of the program disclosing the information
Name of person, agency or organization to whom disclosure is made
Specific information to be disclosed
Purpose of disclosure
Statement of the individual's right to revoke consent (must allow verbal and written revocation)
Expiration date of the consent
Dated signature of individual
Dated signature of witness
Copy offered to the individual
Step 2 Cross-Check: The Primary Therapists will review the informed and voluntary consents with their clients to ensure all consents are completed and signed as required.
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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 review of seven client records, the facility failed to document the acceptance or refusal of consent forms to the client in two of seven records reviewed. Additionally, there was a consent to release information form signed by the client that did not include who the information was being released to, or the information to be released.
Client # 1 was admitted on 05/24/18 and was still an active client at the time of the inspection. The facility failed to document that a copies of consent to release information forms were offered to the client for a consent to release information form to another treatment provider and a consent to release to an unknown source, both dated 05/24/18.
Client # 6 was admitted on 10/04/17 and discharged on 10/31/17. The facility failed to document that a copy of a consent to release information form to "mother" dated 10/04/17 was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Step 1: Upon Admissions through the responsibility of the Admissions/Intake Specialist, the consent for release of information is thoroughly and clearly completed with all required information. The consent for release of information clearly identifies and describes the information to be released and to whom it will be released.
Documentation clearly identifies that the client is offered a copy of the consent for release form. A copy of this completed release form is clearly documented and maintained in all client records.
Step 2 Cross- Check: Upon the initial session with the Primary Therapists, the Primary Therapist will review all their client consents with their clients to ensure all are completed and signed as required.
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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
Based on a review of seven client records, the facility failed to document client rights to include ethnicity, marital status, sexual orientation, handicap, and religion in seven of seven records reviewed.
Client #1 was admitted on 05/24/18 and was an active client at the time of the inspection.
Client #2 was admitted on 05/09/18 and was an active client at the time of the inspection.
Client #3 was admitted on 04/30/18 and was an active client at the time of the inspection.
Client #4 was admitted on 05/17/18 and was an active client at the time of the inspection.
Client #5 was admitted on 01/12/18 and was discharged on 02/09/18.
Client #6 was admitted on 10/04/17 and was discharged on 10/31/17.
Client #7 was admitted on 02/24/18 and was discharged on 03/09/18.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Step 1: The Client Rights, Policies and Procedures is updated before 7/1/2018. The updated policy and procedures are located in the Client Handbook and SP Policy and Procedure Manual.
Upon admission/intake, Client Rights, Policies and Procedures will be reviewed for each and every new client admission. Written acknowledgement by each client is documented that they have been notified of their rights.
Documentation of client rights includes ethnicity, marital status, sexual orientation, handicap and religion. Documentation indicates that the client reviewed and acknowledged the Clients Rights, Policies and Procedures upon the Admission/Intake process.
Step 2 Cross-Check: Upon the initial session with the Primary Therapists, they review the Client Rights, Policies and Procedures with their clients to ensure all are acknowledged, completed and signed as required.
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709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on review of seven client records, the facility failed to document complete treatment plans for clients # 1, 3, 4, 5, 6, and 7.
Client #1 was admitted on 05/24/18 and was an active client at the time of the inspection. There was no documentation of a treatment plan in the client records, however there was an individual session documented on 05/31/18.
Client #3 was admitted on 04/30/18 and was an active client at the time of the inspection. A comprehensive treatment plan developed on 05/15/18 does not have type or frequency included.
Client #4 was admitted on 05/17/18 and was an active client at the time of the inspection. A comprehensive treatment plan developed on 05/23/18 was not signed by the client.
Client #5 was admitted on 01/12/18 and was discharged on 02/09/18. Comprehensive treatment plan did not specify Individual or group.
Client #6 was admitted on 10/04/17 and was discharged on 10/31/17. Comprehensive treatment plan lists type and frequency as "ongoing". Is not specific to Individual or group or how many times per week.
Client #7 was admitted on 02/24/18 and was discharged on 03/09/18. Comprehensive treatment plan does not list type and frequency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Although the plans did exist for all 7 clients identified, all components will be reviewed for completion by the clinical director. Primary Therapists are responsible for the comprehensive development of Treatment Plans for each client assigned to them. Treatment plans include goals, action steps, type and frequency of treatment sessions, including individual, group and holistic sessions. All clients are required to review and sign their Treatment Plan before final submission. The Primary Therapists are responsible to obtain the client signature upon completing the Treatment Plan.
A client record review is done on a weekly basis by the Clinical Director. The review includes diagnostic summaries, treatment plans, notes, case consultations and discharge/continuing care plans. The Clinical Director notifies the Primary Therapist for needed corrections. The Primary Therapist is responsible to take immediate
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709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on review of seven client records, the facility failed to document referral contacts, progress notes, case consultations, and follow-up information in two client records.
Client # 1 was admitted on 05/24/18 and was still an active client at the time of the inspection. There were no individual or group notes documented in the client record.
Client # 6 was admitted on 10/04/17 and discharged on 10/31/17. Medication Seroquel was dispensed at 9:54 pm on 10/8/17 and was not signed off by the client. Gabapentin was dispensed at 9:00 pm on 10/08/17 and was not signed off by the client.
Client #6, prior to discharge, did not have any case consultations documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
There is a complete client record for each and every client at Silver Pines. This record includes all client activity related to their treatment experience. The specific activities include individual sessions, group sessions, progress notes, case consultations, and all continuing care/discharge plans.
During the Admissions process, the Admission/Intake Specialist collects all referral sources contact information, including address and phone numbers. All referral sources are clearly documented in each client's record.
The Primary Therapists are responsible to document individual, weekly and case consultation notes for each and every client. The case management system had an identified error which was fixed by KiPu and now includes all client activity, individual, group, notes and discharge plans, in the CHART SUMMARY tab.
The Clinical Director reviews all client record components to ensure compliance and complete records on a weekly basis. The Clinical Director notifies each Primary Therapist for immediate needed corrections.
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