INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 4, 2022 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of four personnel records, the facility failed to ensure that one facility director was given an annual work performance evaluation.
Employee #1 was hired as a facility director on September 23, 2019 and had not received an annual evaluation at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
HR Administrator will be responsible for monitoring and auditing the completion of annual reviews in a timely manner. The HR Administrator will audit HR files monthly to ensure that reviews are completed. They will remind supervisors to complete the evaluations. Director of Quality Assurance will audit files on a quarterly basis to ensure compliance.
Employee #1 will receive their evaluation on June 3, 2022.
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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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one out of fourteen client records reviewed.
Client #8 was admitted on March 20, 2022 and was discharged on April 13, 2022. There was documentation that a phone call was made to their employer on March 21, 2022; however, there was not a proper consent to release information form signed by the client prior to disclosure.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Care Manager was retrained on consents and disclosure of information on 5/20/22. The clinical staff will be retrained on consents and disclosure of information on 5/25/22 and 6/2/22.
Moving forward, the Care Manager will audit consents and contact notes on a weekly basis. The Director of Quality Assurance will audit consents and contact notes monthly.
Client #8 was discharged at the time of inspection.
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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 a completed consent to release information in one out of fourteen records reviewed, as there were forms that were missing required information.
Client #8 was admitted on March 20, 2022 and was discharged on April 13, 2022. There was a consent to release form, signed and dated on March 21, 2022 to an employer, but the consent form did not include a signature of the client.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Care Manager was retrained on consents on 5/20/22. The clinical staff will be retrained on consents on 5/25/22 and 6/2/22. Moving forward, the Care Manager will audit consents on a weekly basis. The Director of Quality Assurance will audit consents monthly.
Client #8 was discharged at the time of inspection.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document a completed consent to release information in three out of fourteen records reviewed, as there were forms that were missing dated signature of witness.
Client #4 was admitted on March 2, 2022 and was discharge on March 10, 2022. There was a consent to release form, signed and dated by client on March 2, 2022 to a laboratory.
Client #8 was admitted on March 20, 2022 and was discharged on April 13, 2022. There was a consent to release form, signed and dated by client on March 23, 2022 to an employer and a legal entity.
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Care Manager was retrained on consents on 5/20/22. The clinical staff will be retrained on consents on 5/25/22 and 6/2/22. Moving forward, the Care Manager will audit consents on a weekly basis. The Director of Quality Assurance will audit consents monthly.
Client #4 was discharged at the time of inspection.
Client #8 was discharged at the time of inspection.
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709.62(c)(2)(i) LICENSURE Orientation Proj policies
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(i) Project policies, which include the following:
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Observations
Based on a review of client records, the facility failed to include documentation of a client orientation which includes familiarization of project policies in seven out of seven records reviewed.
Client #1 was admitted on March 18, 2022 and was discharged on March 20, 2022.
Client #2 was admitted on February 28, 2022 and was discharged on March 2, 2022.
Client #3 was admitted on December 15, 2021 and was discharged on December 20, 2021.
Client #4 was admitted on March 2, 2022 and was discharged on March 10, 2022.
Client #5 was admitted on April 29, 2022 and was still active at the time of the inspection.
Client #6 was admitted on April 29, 2022 and was still active at the time of the inspection.
Client #7 was admitted on April 14, 2022 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection. .
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Plan of Correction
Director of Quality Assurance created a form on in the EMR that all clients will sign upon intake. The form was created on 5/20/22. All staff will be trained on proper way to orient the client to the program and the purpose of this form by 5/27/22. Moving forward, the Director of Quality Assurance will audit the forms monthly to ensure that clients are completing them.
Client #1 was discharged at the time of inspection.
Client #2 was discharged at the time of inspection.
Client #3 was discharged at the time of inspection.
Client #4 was discharged at the time of inspection.
Client #5 has since been discharged.
Client #6 has since been discharged.
Client #7 has since been discharged.
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709.62(c)(2)(iii) LICENSURE Orientation - Fee Schedule
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(2) Client orientation to the project which includes, but is not limited to a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to include documentation of a client orientation which includes familiarization of the fee schedule in seven out of seven records reviewed.
Client #1 was admitted on March 18, 2022 and was discharged on March 20, 2022.
Client #2 was admitted on February 28, 2022 and was discharged on March 2, 2022.
Client #3 was admitted on December 15, 2021 and was discharged on December 20, 2021.
Client #4 was admitted on March 2, 2022 and was discharged on March 10, 2022.
Client #5 was admitted on April 29, 2022 and was still active at the time of the inspection.
Client #6 was admitted on April 29, 2022 and was still active at the time of the inspection.
Client #7 was admitted on April 14, 2022 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director of Quality Assurance and Financial Coordinator updated a form in the EMR to include the fee schedule on 5/20/22. The Care Manager was trained on these changes on 5/23/22 and how to include this with the intake process. Moving forward, the Director of Quality Assurance will audit the forms monthly to ensure that clients are completing them.
Client #1 was discharged at the time of inspection.
Client #2 was discharged at the time of inspection.
Client #3 was discharged at the time of inspection.
Client #4 was discharged at the time of inspection.
Client #5 has since been discharged.
Client #6 has since been discharged.
Client #7 has since been discharged.
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709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to include documentation of a client orientation which includes familiarization of project policies in seven out of seven records reviewed.
Client #8 was admitted on March 20, 2022 and was discharged on April 13, 2022.
Client #9 was admitted on January 5, 2021 and was discharged on February 7, 2022.
Client #10 was admitted on December 24, 2021 and was discharged on January 27, 2022.
Client #11 was admitted on April 18, 2022 and was still active at the time of the inspection.
Client #12 was admitted on April 11, 2022 and was still active at the time of the inspection.
Client #13 was admitted on April 2, 2022 and was still active at the time of the inspection.
Client #14 was admitted on April 26, 2022 and was still active at the time of the inspection
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Director of Quality Assurance created a form on in the EMR that all clients will sign upon intake. The form was created on 5/20/22. All staff will be trained on proper way to orient the client to the program and the purpose of this form by 5/27/22. Moving forward, the Director of Quality Assurance will audit the forms monthly to ensure that clients are completing them.
Client #8 was discharged at the time of inspection.
Client #9 was discharged at the time of inspection.
Client #10 was discharged at the time of inspection.
Client #11 has since been discharged.
Client #12 has since been discharged.
Client #13 has since been discharged.
Client #14 has since been discharged.
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709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to include documentation of a client orientation which includes familiarization of the fee schedule in seven out of seven records reviewed.
Client #8 was admitted on March 20, 2022 and was discharged on April 13, 2022.
Client #9 was admitted on January 5, 2022 and was discharged on February 7, 2022.
Client #10 was admitted on December 24, 2021 and was discharged on January 27, 2022.
Client #11 was admitted on April 18, 2022 and was still active at the time of the inspection.
Client #12 was admitted on April 11, 2022 and was still active at the time of the inspection.
Client #13 was admitted on April 2, 2022 and was still active at the time of the inspection.
Client #14 was admitted on April 26, 2022 and was still active at the time of the inspection.
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Director of Quality Assurance and Financial Coordinator updated a form in the EMR to include the fee schedule on 5/20/22. The Care Manager was trained on these changes on 5/23/22 and how to include this with the intake process. Moving forward, the Director of Quality Assurance will audit the forms monthly to ensure that clients are completing them.
Client #8 was discharged at the time of inspection.
Client #9 was discharged at the time of inspection.
Client #10 was discharged at the time of inspection.
Client #11 has since been discharged.
Client #12 has since been discharged.
Client #13 has since been discharged.
Client #14 has since been discharged.
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