INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 2-3, 2023, 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 LLC, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that all counselors met the appropriate educational and/or experiential qualifications for the position in one of four applicable personnel records reviewed. Employee # 4 was hired as a counselor on December 15, 2021. The employee had a high school diploma and did not have qualifying certifications.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 job title has been changed and is no longer titled Counselor. Employee #4 has been given until March 2024 to get enrolled and begin the process of getting the right certifications in order to go back to the title of Counselor once those certifications are completed. Moving forward all potential counselors will only be considered for a position if they meet all requirements in order to be a counselor. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in three of six applicable personnel records reviewed. Employee # 3 was hired as a counselor on January 17, 2021 and was due to have HIV/AIDS and TB/STD training no later than January 17, 2022. The HIV/Aids and TB/STD training were not completed at the time of the inspection.Employee # 4 was hired as a counselor on December 15, 2021 and was due to have HIV/AIDS and TB/STD training no later than December 15, 2022. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection. Employee # 6 was hired as the BHT Supervisor on September 30, 2019 and was due to have HIV/AIDS and TB/STD training no later than September 30, 2021. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection. This is a repeat citation from the September 15, 2022 annual licensing inspection These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has given all employees until 12/15/23 to get all of their required hours for HIV/AIDS and TB/STD trainings completed. The facility has a new system in place that includes a tracking system of all the CEUS that each employee is required and when they are each due. HR will them make sure to notify the staff member of when they will need to get their hours completed by. If the employees do not get their trainings completed by the time frame needed they will be docked pay until they get them done. |
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 and personnel training records, the facility failed to ensure that two of four counselors completed at least 25 clock hours of annual training for the facility ' s 2022 training year reviewed.Employee # 3 was hired as a counselor on January 17, 2021. The personnel training record documented 6 hours of annual training for the reviewed training year.Employee # 4 was hired as a counselor assistant on December 15, 2021. The personnel training record documented 0 hours of annual training for the reviewed training year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 and employee #4 as well as all current employees who required CEUS have been given until 12/15/23 to show proof of CEUs and or to get caught up for the year of 2023. Moving forward there will be a new system in place that will be able to track all employees required CEU hours and to make sure that they are being completed. HR will notify each employee when they are coming up on their required hours and let them know a date that it needs to be completed by. All new employees will be told on orientation that this is a part of their job description. If CEUs are not completed by the date they are needed to be completed the employee will be docked pay until they are completed. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility failed to document, and make available to the public, an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders.This is a repeat citation from the September 15, 2022 annual licensing renewal inspection.This finding was discussed with facility staff during the licensing process.
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Plan of Correction
The facility has since put up a form in the client area that shows the names of the officers, directors, and principle shareholders. The facility will also make sure to put this on their website in a place that is visible to anyone who visits the site. This will be updated if needed if anything shall change immediately on both the website and on site. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to document that the project director had prepared, annually updated and signed the facility's written manual, which delineates the project policies and procedures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has had the project director sign the policies and procedure manual. The project director will go over the policies and procedures every January. During that time the administrative team will review any changes that need to be made and or policies that need to be added. The policies will be edited and then signed and updated by the project director.
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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 one of seven outpatient client records reviewed. Client # 1 was admitted on September 2, 2022 and was active at the time of inspection. A release of information form to a funding source was signed by the client and witness on September 2, 2022; However, there was evidence of disclosures made to a different funding source without a signed consent to release information.This is a repeat citation from the September 21, 2021 and September 15, 2022 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1's chart has since been updated and has signed the release for the funding source that was not signed. All staff is to complete a training on consents and how to make sure that they are valid and we are not breaking any HIPPA laws. The staff will have this training at their all staff meeting 11/30/23 by the Clinical Director. For all new employees this is now going to be apart of the orientation and a training that will be required for them to complete before beginning employment.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client records reviewed.Client # 7 was admitted on March 30, 2023 and was administratively discharged on April 11, 2023. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Due to client #7 being discharged in April 2023 unfortunately this client was not provided the correct services and was not given a proper notification of their discharge. All clinical staff has been given a training by the Clinical Director at their clinical meeting on 11/16/23. Moving forward any client that is to be involuntarily terminated will be given notice in writing of the decision why they are discharging client and will be uploaded into the client's EMR chart as well. |
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 provide individual counseling sessions two times weekly in four of seven client records reviewed in the partial hospitalization level of care.Client #8 was admitted on June 5, 2023 and was discharged June 26, 2023. There was no documentation of individual counseling sessions being conducted two times a week for the weeks of May 5 thru May 13, 2023. Client #9 was admitted on October 26, 2022 and was discharged November 29, 2022. There was no documentation of individual counseling sessions being conducted two times a week for the weeks of October 10 thru November 2, 2022 and November 14 thru November 29, 2022. Client #13 was admitted June 7, 2023 and was discharged June 22, 2023. There was no documentation of individual counseling sessions being conducted two times a week for the week of June 7 thru June 14, 2023. Client #14 was admitted March 30, 2023 and was discharged May 2, 2023. There was no documentation of individual counseling sessions being conducted two times a week for the week of April 2 thru April 19, 2023. This is a repeat citation from the September 21, 2021 and September 15, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For client #8, 9, 13 and 14 the counselors went back into their charts and wrote a late entry note for a missed session and explained why there was a missed session for their second session. Counselors were given a training about the requirements of PHP clients back in May 2023. They have also been getting weekly audit reports by the clinical director to show them which client needs two sessions a week. This way the counselor is able to make sure to get those sessions done. If they are unable to meet for both sessions there is a missed session or general note completed to explain why they are unable to complete a session. |
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 document that treatment plans were reviewed and updated at least every sixty days in three of seven client records reviewed. Client #1 was admitted September 2, 2022 and was active at the time of inspection. A comprehensive treatment plan was completed on September 8, 2022 and a treatment plan update was due no later than November 8, 2022. However, the treatment plan was not completed until August 29, 2023. Client #4 was admitted October 21, 2022 and was discharged May 24, 2023. A treatment plan update was completed on January 18, 2023 and a treatment plan update was due no later than March 18, 2023. However, the treatment plan was not completed until April 19, 2023Client # 6 was admitted August 5, 2022 and was discharged August 9, 2023. A treatment plan update was completed on October 5, 2022 and a treatment plan update was due no later than December 5, 2022. However, the treatment plan was not completed until January 11, 2023. This is a repeat citation from the September 21, 2021 and September 15, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor went in client #1 chart and created a brand new treatment plan. Unfortunately client #4 and 6's chart will not be able to be updated as they are discharged. All counselors were given training at clinical meeting 11/16/23 on treatment plans and treatment plan reviews. Clinical Director sends out a weekly audit report they will let counselors know when a treatment plan review or new treatment plan is due. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on an administrative review, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for providing individual counseling sessions two times weekly were submitted and approved by the Department for the September 21, 2021 and September 15, 2022 annual licensing inspections. Not providing individual counseling sessions two times weekly was again found to be deficiency during the October 2-3, 2023 annual licensing inspection.Plans of correction for ensuring that treatment plans were reviewed and updated at least every sixty days were submitted and approved by the Department for the September 21, 2021 and September 15, 2022 annual licensing inspections. Not ensuring treatment plans were reviewed and updated every sixty days was again found to be deficiency during the October 2-3, 2023 annual licensing inspection.Plans of correction ensuring the facility would obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record were submitted and approved by the Department for the September 21, 2021 and September 15, 2022 annual licensing inspections. Not obtaining an informed and voluntary consent form from the client for the disclosure of information contained in the client record was again found to be a deficiency during the October 2-3, 2023 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff will be trained at the all staff meeting at end of month on requirements for informed consents. The clinical team has been given an updated training on treatment plans and individual sessions at their clinical meeting 11/16/23. The counselors are also given an audit report weekly that will help to ensure that they know what client needs two sessions and when treatment plan reviews and new treatment plans are due. |