INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 18. 2023 through May 19, 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 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:
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors, who have not functioned for 2 years as supervisors in the provision of clinical services, completed a core curriculum in clinical supervision in one of one applicable personnel record reviewed.
Employee # 2 was hired as a clinical supervisor on August 1, 2022. There was no documentation of clinical supervision experience prior to being hired and no documentation that the clinical supervision core curriculum training was completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Quality Assurance will train the HR Administrator on HR requirements for this position on 6/2/23. Moving forward, the Director of Quality Assurance will work with the HR Administrator to ensure that any newly hired Clinical Supervisors and Lead Clinicians who do not have supervisor experience complete a clinical supervision training within 6 months of hire. Director of Quality Assurance will routinely audit this to ensure compliance.
Employee #2 is registered to take the Clinical Supervisor training in Palmerton from June 26, 2023 to June 30, 2023.
|
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all counselor assistants, with a high school diploma or General Education Development (GED), were counseling clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment and under the close supervision of a trained counselor or clinical supervisor for the next 9 months of employment.
Employee # 9 was hired as a high school diploma/GED-level counselor assistant on October 3, 2022. The supervision notes did not indicate that close supervision, defined as formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week, was occurring once a week during the months of February 2023, March 2023, and April 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Quality Assurance will train the HR Administrator on HR requirements for this position on 6/2/23. Moving forward, the Director of Quality Assurance will work with the HR Administrator to ensure proper supervision of a Counselor's Assistant. The Director of Quality Assurance will audit HR files on a quarterly basis to ensure compliance.
The Clinical Director will closely supervise Employee #9 until the end of the of his nine months which wil be in September 2023. The Clinical Director will document these supervision in the employees file, which will include a case study and direct observation. The Clinical Director will observe and meet with Employee #9 on a weekly basis.
|
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that frozen food was kept at or below 0 degrees Fahrenheit. At approximately 11:30 AM on May 18, 2023, the temperature of the freezer in the detox lounge was measured at 10 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Moving forward, the Executive Chef will work with the Director of Quality Assurance to ensure that the temperatures remain within DDAP standards. The standard temperatures were reviewed with the Executive Chef on 5/30/23. The Director of Quality Assurance will routinely audit temperature logs to ensure compliance.
The freezer temperature in the detox lounge was lowered to be in 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.
|
Observations
Based on a review of client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in one of two 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 # 7 was admitted to the inpatient non-hospital detoxification activity on February 27, 2023 and was discharged against medical advice on March 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.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director will retrain staff on the Against Professional Advice policy and ensuring that the emergency contact is notified, and the notification is documented on an agency form in the EMR. This training will take place on 6/8/23. Moving forward, the Director of Quality Assurance and Clinical Director will audit APA discharges monthly to ensure compliance.
Client #7 has been discharged and the family was notified.
|
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.
|
Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of fourteen client records reviewed.
Client # 8 was admitted to the inpatient non-hospital activity on April 24, 2023 and was active at the time of the inspection. There was evidence of disclosures to a family member during a family counseling session on May 9, 2023; 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.
|
Plan of Correction
The Executive Director will retrain the Clinical Team on 6/8/23 on ensuring prior to a family session occurring, that all individuals who are attending the session have a consent signed. Moving forward, the Director of Quality Assurance and the Clinical Director will audit client records on a regular basis to ensure compliance with this standard.
Client #8 has since been discharged from the program.
|
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in one of one applicable client record reviewed.
Client # 13 was admitted to the inpatient non-hospital activity on February 17, 2023 and was discharged on March 27, 2023. The individual treatment and rehabilitation plan was completed on February 20, 2023 and the first update was due no later than March 20, 2023; however, there was no update completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director will retrain the Clinical Team on 6/8/23 on the proper documentation timeframes, including but not limited to the procedure for updating treatment plans. Moving forward, the Director of Quality Assurance and the Clinical Director will audit treatment plans on a regular basis to ensure compliance.
Client #13 is no longer in services.
|