INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 28, 2021 through September 29, 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 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the facility-submitted Staffing Requirements Facility Summary Report, the facility failed to ensure that the full-time equivalent (FTE) counselor caseload in their outpatient program did not exceed 35 active clients. The FTE is determined by dividing the total number of counselor hours devoted to clients by the facility's standard workweek. Then, to obtain the individual ratio, the total number of active clients is divided by the FTE.The FTE counselor caseload for Employee # 2, hired as a clinical supervisor on May 12, 2021, is as follows: 10/40 = .25 (FTE); 9/.25 = 36, which equals to a FTE counselor/client ratio of 36:1.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director will speak with clinical supervisor and further evaluate all counselor caseloads. There was a misunderstanding of counselor/client caseload. The FTE was a misunderstanding and will be monitored and ensure compliance. Clinical director will review FTE with clinical supervisor and explain the FTE is determined by dividing the total number of counselor hours devoted to clients by the facility's standard workweek. Then, to obtain the individual ratio, the total number of active clients is divided by the FTE. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on September 29, 2021, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room and that counseling room walls shall extend from the floor to the ceiling. The large room, located at the back of the facility, is identified as a multipurpose room that is utilized for group counseling sessions, as well as other activities. There is a room divider to ensure privacy during group counseling sessions; however, the room divider was not installed at the time of inspection. This allowed group counseling sessions to be seen and heard outside the counseling room. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
wall of the multi-purpose room was extended while inspector was onsite. Issue has been corrected all wall will remain extended to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Clinical director and clinical supervisor will ensure wall remains extended to ensure privacy. |
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 own written procedures for the management of treatment/rehabilitation services in six of fourteen client records reviewed.Client # 8 was admitted to the partial hospitalization level of care on August 30, 2021 and was still active at the time of inspection. The written procedure manual stated that partial hospitalization level of care treatment plan updates would be completed within 15 days. The client's comprehensive treatment plan was completed on September 1, 2021 and the first update was due no later than September 16, 2021; however, the update was not completed at the time of inspection. Client # 9 was admitted to the partial hospitalization level of care on September 1, 2021 and was still active at the time of inspection. The written procedure manual stated that partial hospitalization level of care treatment plan updates would be completed within 15 days. The client's comprehensive treatment plan was completed on September 9, 2021 and the first update was due no later than September 24, 2021; however, the update was not completed at the time of inspection. Client # 10 was admitted to the partial hospitalization level of care on September 8, 2021 and was still active at the time of inspection. The written procedure manual stated that partial hospitalization level of care treatment plan updates would be completed within 15 days. The client's comprehensive treatment plan was completed on September 10, 2021 and the first update was due no later than September 25, 2021; however, the update was not completed at the time of inspection. Client # 11 was admitted to the partial hospitalization level of care on June 1, 2021 and was discharged on July 12, 2021. The written procedure manual stated that partial hospitalization level of care treatment plan updates would be completed within 15 days. The client's comprehensive treatment plan was completed on June 3, 2021 and the first update was due no later than June 18, 2021; however, the update was completed on July 7, 2021. Client # 13 was admitted to the partial hospitalization level of care on June 14, 2021 and was discharged on July 16, 2021. The written procedure manual stated that partial hospitalization level of care treatment plan updates would be completed within 15 days. The client's comprehensive treatment plan was completed on June 18, 2021 and the first update was due no later than July 3, 2021; however, the update was not completed prior to discharge.Client # 14 was admitted to the partial hospitalization level of care on July 19, 2021 and was discharged on August 9, 2021. The written procedure manual stated that partial hospitalization level of care treatment plan updates would be completed within 15 days. The client's comprehensive treatment plan was completed on July 21, 2021 and the first update was due no later than August 5, 2021; however, the update was not completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director has designed an excel spreadsheet that is to be submitted the end of the week to clinical director and clinical supervisor for review. Spreadsheet will include date of initial treatment plan, master treatment plan, and last treatment plan update to better ensure compliance. Policy and procedure will be reviewed as well and all staff will sign an understanding of SLRC policy and procedure and corrective plan of action for noncompliance. |
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 a written informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in one of fourteen client records reviewed.Client # 6 was admitted to the outpatient level of care on June 11, 2021 and was discharged on August 9, 2021. There was documentation of a facsimile that was sent to a government agency on August 9, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client is currently discharged and unable to sign a release of information at this time. Clinical director advised all staff members of confidentiality requirements in ALL Staff meeting on 10/5. Clinical director will have staff members that engage with clients complete continued education on confidentiality to further educate and prevent future occurrences. |
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 client records, the facility failed to keep the specific information to be released on consent to release information forms within the limits established by 4 Pa. Code 255.5 (a)(6) in one of fourteen client records reviewed.Client # 3 was admitted to the outpatient level of care on June 28, 2021 and was still active at the time of inspection. A release of information form to an employer was signed and dated by the client on June 28, 2021 and the form allowed for the release of client prognosis, brief statement on relapse and frequency, progress in treatment, and nature of the project-all of which exceeded the limits established by 4 Pa. Code 255.5(6). These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director will update release of information for employers to reflect presence in treatment. Primary counselor will discuss limitations with client, rescind release, and sign updated release that does not indicate the release of client prognosis, brief statement on relapse and frequency, progress in treatment, and nature of the project
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of client on a release of information form in one of fourteen client records reviewed. Client # 8 was admitted to the partial hospitalization level of care on August 30, 2021 and was still active at the time of inspection. There was a release of information form to a pharmacy that was signed and dated by staff on September 8, 2021; however, the dated signature of the client was not documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client is currently discharged and unable to sign a release of information at this time. Clinical supervisor will review and monitor charts ongoing to ensure all releases of information are signed. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in fourteen of fourteen client records reviewed.In every client record reviewed, the non-discrimination rights acknowledgement form was missing creed, color, national origin, marital status, and religion.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director will amend to: Silver Linings may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. All current clients will have this reviewed and written acknowledgement that they have been notified. This information will be updated in consent; therefore, all future clients will be notified and acknowledge in writing. Clinical director will also ensure all staff are aware of amendment and to explain to clients. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in fourteen of fourteen client records reviewed.In every client record reviewed, the client rights acknowledgement form did not include the notification of this regulatory client right.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director will amend "consent to use and disclose PHI": Client has the right to appeal a decision limiting access to their records to the director. All current clients will have this reviewed and written acknowledgement that they have been notified. This information will be updated in consent; therefore, all future clients will be notified and acknowledge in writing. Clinical director will also ensure all staff are aware of amendment and to explain to clients. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in fourteen of fourteen client records reviewed.In every client record reviewed, the client rights acknowledgement form did not include the notification of this regulatory client right.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director will amend "consent to use and disclose PHI": Client has the right to submit rebuttal data or memoranda to their own records. All current clients will have this reviewed and written acknowledgement that they have been notified. This information will be updated in consent; therefore, all future clients will be notified and acknowledge in writing. Clinical director will also ensure all staff are aware of amendment and to explain to clients. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that all clients admitted to the partial hospitalization program received individual counseling services at least twice weekly in six of seven applicable client records reviewed. Client # 8 was admitted to the partial hospitalization level of care on August 30, 2021 and was still active at the time of inspection. During the week of September 5 - 11, 2021, there was one documented individual counseling service occurring on September 7, 2021. Additionally, during the week of September 19 - 25, 2021, there was one documented individual counseling service occurring on September 23, 2021.Client # 9 was admitted to the partial hospitalization level of care on September 1, 2021 and was still active at the time of inspection. During the week of September 5 - 11, 2021, there was not any individual counseling services documented. Additionally, during the week of September 12 - 18, 2021, there was one documented individual counseling service occurring on September 13, 2021.Client # 10 was admitted to the partial hospitalization level of care on September 8, 2021 and was still active at the time of inspection. During the week of September 19 - 25, 2021, there was one documented individual counseling service occurring on September 24, 2021.Client # 11 was admitted to the partial hospitalization level of care on June 1, 2021 and was discharged on July 12, 2021. During the week of June 13 - 19, 2021, there was one documented individual counseling service occurring on June 15, 2021.Client # 12 was admitted to the partial hospitalization level of care on May 10, 2021 and was discharged on June 23, 2021. During the week of May 16 - 22, 2021, there was one documented individual counseling service occurring on May 19, 2021.Client # 14 was admitted to the partial hospitalization level of care on July 19, 2021 and was discharged on August 9, 2021. During the week of July 25 - 31, 2021, there was one documented individual counseling service occurring on July 28, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical director has designed an excel spreadsheet that is to be submitted the end of the week to clinical director and clinical supervisor for review. Spreadsheet will include last individual, next individual, and requirements to better ensure compliance. Policy and procedure will be reviewed as well and all staff will sign an understanding of SLRC policy and procedure and corrective plan of action for noncompliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that outpatient treatment and rehabilitation plans are reviewed and updated at least every sixty days in three of seven applicable client records reviewed.Client # 1 was admitted to the outpatient level of care on May 13, 2021 and was still active at the time of inspection. A treatment plan update was completed on July 19, 2021 and the next update was due no later than September 19, 2021; however, the update was not completed at the time of inspection.Client # 2 was admitted to the outpatient level of care on May 28, 2021 and was still active at the time of inspection. A treatment plan update was completed on July 19, 2021 and the next update was due no later than September 19, 2021; however, the update was not completed at the time of inspection.Client # 3 was admitted to the outpatient level of care on June 28, 2021 and was still active at the time of inspection. The comprehensive treatment plan was completed on June 30, 2021 and the first update was due no later than August 30, 2021; however, the update was not completed at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff assigned to client 1, 2, and 3 are no longer employed at Silver Linings.
However, clinical director has designed an excel spreadsheet that is to be submitted the end of the week to clinical director and clinical supervisor for review. Spreadsheet will include treatment plan update to help clinician and supervisor know when next treatment plan update is due along with requirements to better ensure compliance. Policy and procedure will be reviewed as well and all staff will sign an understanding of SLRC policy and procedure and corrective plan of action for noncompliance. |