INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19-20, 2024, 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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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 completion of 25 clock hours of annual training required for counselors in one of five applicable employee records reviewed.
Employee #6 was hired as a counselor on March 4, 2020, and was still in the position as of the date of the onsite inspection. The reviewed facility training year was from January 1, 2023, through December 31, 2023. Employee #6's employee record only documented 21.5 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director reviewed with Employee #6 the importance of completing training requirements in a timely manner on 4/8/24.
Moving forward, HR Generalist will audit staff trainings on a monthly basis to ensure assigned trainings are being completed. The Director of Quality Assurance will audit trainings on a quarterly basis to ensure compliance. |
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 detox and residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in eight of eight applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in DDAP Licensing Alert 02-21.
Client # 8 was admitted to the inpatient non-hospital detoxification activity on December 19, 2023, and was discharged against medical advice on January 18, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client # 9 was admitted to the inpatient non-hospital detoxification activity on November 20, 2023, and was discharged against medical advice on November 27, 2023. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client # 10 was admitted to the inpatient non-hospital detoxification activity on January 15, 2024, and was discharged against medical advice on January 29, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client # 11 was admitted to the inpatient non-hospital detoxification activity on November 6, 2023, and was discharged against medical advice on November 9, 2023. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #15 was admitted to the inpatient non-hospital rehabilitation activity on November 20, 2023, and was discharged against medical advice on December 4, 2023. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #16 was admitted to the inpatient non-hospital rehabilitation activity on September 22, 2023, and was discharged against medical advice on October 12,2023. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #18 was admitted to the inpatient non-hospital rehabiliation activity on January 13, 2024, and was discharged against medical advice on February 2, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client #21 was admitted to the inpatient non-hospital rehabilitation activity on January 2, 2024, and was discharged against medical advice on January 11, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
This is a repeat citation from the May 19, 2023 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed and retrained staff on completion of documentation for a client who leaves APA on 3/21/24.
Moving forward, Office Manager will audit all discharge clients to ensure that all discharge paperwork is completed in client chart.
The Executive Director and Director of Quality Assurance will perform random audits on clients who left APA to ensure that documentation has been completed. |
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 client detox records, the facility failed to 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 the name of the person, agency or organization to whom disclosure is made in one out of fifteen applicable client records.
Client #8 was admitted on December 19, 2023, and was discharged January 18, 2024. A consent to release form was signed and dated on December 19, 2023, that did not specify to whom the information would be released.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be retrained on confidentiality and consents by 4/26/24.
Moving forward, staff will be trained on a quarterly basis on the importance of confidentiality and consents. The Director of Quality Assurance will audit regularly to ensure compliance.
Client #8 was no longer in services. |
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 detox and residential client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in fifteen out of fifteen applicable client records reviewed.
Client #1 was admitted on March 9, 2024, and was still active at the time of the inspection. On two consents dated March 9, 2024, to a treatment facility and an insurance provider there was no documentation of a copy being offered to the client.
Client #2 was admitted on March 16, 2024, and was still active at the time of the inspection. A consent form dated March 16, 2024, to a treatment facility did not contain documentation of a copy being offered to the client.
Client #3 was admitted on March 15, 2024, and was still active at the time of the inspection. A consent form dated March 15, 2024, to family member did not contain documentation of a copy being offered to the client. Additionally, a consent form dated March 18, 2024 to an employer did not contain documentation of a copy being offered to the client.
Client #4 was admitted on October 25, 2023, and was discharged on November 1, 2023. A consent form dated October 25, 2023, to an insurance provider did not contain documentation of a copy being offered to the client.
Client #5 was admitted on January 12, 2024, and was discharged on January 18, 2024. A consent form dated January 12, 2024, for an emergency contact did not contain documentation of a copy being offered to the client. Additionally, a consent form dated January 13, 2024, to an insurance provider did not contain documentation of a copy being offered to the client.
Client #6 was admitted on November 6, 2023, and was discharged on November 13, 2023. A consent form dated November 6, 2023, for an insurance provider did not contain documentation of a copy being offered to the client.
Client #7 was admitted on January 16, 2024, and was discharged on January 30, 2024. A consent form dated January 16, 2024, for an insurance provider did not contain documentation of a copy being offered to the client.
Client #8 was admitted on December 19, 2023, and was discharged on January 18, 2024. A consent form dated December 19, 2023, for a third-party payer did not contain documentation of a copy being offered to the client.
Client #12 was admitted on February 25, 2024, and was still active at the time of the inspection. A consent form dated February 25, 2024, to an insurance provider did not contain documentation of a copy being offered to the client.
Client #13 was admitted on March 13, 2024, and was still active at the time of the inspection. A consent form dated March 14, 2024, to an insurance provider did not contain documentation of a copy being offered to the client. Additionally, a consent form dated March 18, 2024, to an attorney did not contain documentation of a copy being offered to the client.
Client #14 was admitted on February 28, 2024, and was still active at the time of the inspection. A consent form dated February 28, 2024, to an insurance provider did not contain documentation of a copy being offered to the client.
Client #15 was admitted on November 20, 2023, and was discharged on December 4, 2023. A consent form dated November 20, 2023, for an insurance provider did not contain documentation of a copy being offered to the client.
Client #16 was admitted on September 22, 2023, and was discharged on October 12, 2023. A consent form dated September 26, 2023, for a probation officer did not contain documentation of a copy being offered to the client.
Client #17 was admitted on October 10, 2023, and was discharged on November 1, 2023. A consent form dated October 10, 2023, for an insurance provider did not contain documentation of a copy being offered to the client.
Client #18 was admitted on January 13, 2024, and was discharged on February 2, 2024. A consent form dated January 13, 2024, for an insurance provider did not contain documentation of a copy being offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Quality Assurance updated the consent form to ensure the required statement was on the consent form on 4/9/24.
All staff will be trained on the change to the consent form by 4/26/24.
Moving forward, Director of Quality Assurance will routinely audit to ensure compliance.
All clients have been discharged from services. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on the review of detox client records, the facility failed to document a complete psychosocial evaluation in two out of four applicable records.
Client #6 was admitted on November 6, 2023, and was discharged November 16, 2023. The clinical summary did not contain any clinical impressions or assessments.
Client #7 was admitted on January 16, 2024 and was discharged on January 30, 2024. The facility's policy is to complete the psychosocial within seven business days of admission. At the time of the client's discharge the psychosocial was incomplete.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director will train all clinical staff on the completion of clinical summary in the psychosocial assessment. Clinical staff will all be trained by 4/22/24.
Moving forward, Clinical Director and Director of Quality Assurance will audit on a regular basis to ensure compliance.
Client #6 and #7 were discharged at the time of inspection. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of detox client records, the facility failed to document a follow-up contact within guidelines established by the facility's policy and procedures manual in four out of six applicable records reviewed. The facility's policy and procedures manual states that follow-up contacts will occur one week after discharge from treatment.
Client #5 was admitted on January 12, 2024, and was discharged on January 18, 2024. The follow-up contact was due no later than January 25, 2024; however, it was not documented until January 30, 2024.
Client #6 was admitted on November 6, 2023, and was discharged on November 16, 2023. The follow-up contact was due no later than November 23, 2023; however, it was not documented until November 27, 2023.
Client #9 was admitted on November 20, 2023, and was discharged on November 27, 2023. The follow-up contact was due no later than December 4, 2023; however, there were no follow-up contacts documented in the client record.
Client #11 was admitted on November 6, 2023, and was discharged on November 9, 2023. The follow-up contact was due no later than November 16, 2023; however, it was not documented until November 21, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Director of Quality Assurance made adjustments to current policy to ensure follow up is done within 30 days of discharge from programming.
Staff was trained on this policy on 4/9/24.
Director of Quality Assurance will routinely audit charts for compliance.
Clients have all been discharged at the time of inspection. |
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 a review of residential client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in six out of six applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed between within 10 days following admission.
Client #12 was admitted on February 25, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 6, 2024; however, it was not completed until March 14, 2024.
Client #14 was admitted February 28, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was observed in the client record; however, it was not signed or dated by the client.
Client #15 was admitted on November 20, 2023, and was discharged on December 4, 2023. A comprehensive treatment plan was due no later than November 30, 2023; however, it was not completed until December 3, 2023.
Client #16 was admitted September 22, 2023, and discharged on October 12, 2023. A comprehensive treatment plan was observed in the client record; however, it was not signed or dated by the client.
Client #17 was admitted on October 10, 2023, and was discharged on November 1, 2023. A comprehensive treatment plan was due no later than October 20, 2023; however, it was not completed until October 26, 2023.
Client #18 was admitted on January 13, 2024, and discharged on February 2, 2024. A comprehensive treatment plan was due no later than January 23, 2024; however, it was not completed until January 24, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will retrain clinical staff on the completion of treatment plans, timeframe for completion and required areas of a treatment plan. All staff will be retrained by 4/22/24.
Moving forward, Clinical Director and Director of Quality Assurance will routinely audit charts to ensure compliance.
Client 12 and 14 have since been discharged from 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.
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Observations
Based on a review of residential client records, the facility failed to document proposed type of support service on individual treatment plans in two out of six applicable records reviewed.
Client #14 was admitted on February 28, 2024, and was still active at the time of the inspection. The comprehensive treatment plan had not been dated or signed by the client.
Client #17 was admitted on October 10, 2023, and was discharged on November 1, 2023. The treatment plan was dated November 26, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director of Quality Assurance added a section to the treatment plan to document support services.
Clinical Director will train clinical staff on the addition to the treatment plan and expectations around documentation of support services. All staff will be retrained by 4/22/24.
Moving forward, Clinical Director and Director of Quality Assurance will routinely audit charts to ensure compliance.
Client 14 and 17 have since been discharged from 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.
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Observations
Based on a review of residential client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in two out of five applicable records reviewed. The facility's policy and procedures manual states that a case consultation must be completed within two weeks of admission.
Client #16 was admitted on September 22, 2023, and was discharged on October 12, 2023. A case consultation was due no later than October 6, 2023; however, there was no case consultation documented in the client record.
Client #17 was admitted on admitted on October 10, 2023, and discharged on November 1, 2023. A case consultation was due no later than October 24, 2023; however, there was no case consultation documented in the client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will retrain staff on completion of Case Consults and the timeframe for documentation on 4/22/24.
Moving forward, the Clinical Director and Director of Quality Assurance will routinely audit to ensure compliance.
Client 16 and 17 were discharged at the time of inspection. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of residential client records, the facility failed to document a follow-up contact within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states that follow-up contacts will occur one week after discharge from treatment.
Client #16 was admitted on September 22, 2023, and was discharged on October 12, 2023. The follow-up contact was due no later than October 19, 2023; however, it was not documented until October 25, 2023.
Client #17 was admitted on October 10, 2023, and was discharged on November 1, 2023. The follow-up contact was due no later than November 8, 2023; however, it was not documented until November 13, 2023.
Client #19 was admitted on August 23, 2023, and was discharged on September 20, 2023. The follow-up contact was due no later than September 27, 2023; however, it was not documented until September 29, 2023.
Client #20 was admitted on August 29, 2023, and was discharged on October 3, 2023. The follow-up contact was due no later than October 10, 2023; however, there were no follow-up contacts documented until October 12, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Director of Quality Assurance made adjustments to current policy to ensure follow up is done within 30 days of discharge from programming.
Staff was trained on this policy on 4/9/24.
Director of Quality Assurance will routinely audit charts for compliance.
Clients have all been discharged at the time of inspection. |