INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2019 through September 19, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Silver Linings USA Limited Liability Corporation, 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to identify on their fire drill log the amount of time it took for evacuation, problems encountered and whether the fire alarm or smoke detector was operative during drills conducted in December 2018 through August 2019. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director added a section to the existing fire drill log to incorporate duration, issues or problems encountered and will be sending an exemption letter to the department for an alternative sounding device since the current fire system encompasses the entire building complex and unrelated units or suites. |
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
The facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in seven of seven partial hospitalization client records reviewed.Client #1 was admitted into the partial hospitalization activity on February 19, 2019 and was active at the time of inspection. The policy and procedure manual stated that treatment plan updates must be completed every 15 days. The client record had completed treatment plan updates; however, treatment plan updates were completed outside the 15day policy.Client #2 was admitted into the partial hospitalization activity on August 7, 2019 and was active at the time of inspection. The written procedure manual stated that the initial treatment plan must be developed within 24 hours from admission; however, the complete initial treatment plan was not completed until August 14, 2019.Client #3 was admitted into the partial hospitalization activity on September 11, 2019 and was active at the time of inspection. The written procedure manual stated that the initial treatment plan must be developed within 24 hours from admission; however, the complete initial treatment plan was not completed until September 18, 2019.Client #4 was admitted into the partial hospitalization activity on January 24, 2019 and was discharged February 13, 2019. The policy and procedure manual stated that treatment plan updates must be completed every 15 days. The client record had completed treatment plan updates; however, treatment plan updates were completed outside the 15day policy.Client #5 was admitted into the partial hospitalization activity on January 14, 2019 and was discharged April 14, 2019. The policy and procedure manual stated that treatment plan updates must be completed every 15 days. The client record had completed treatment plan updates; however, treatment plan updates were completed outside the 15day policy.Client #6 was admitted into the partial hospitalization activity on June 10, 2019 and was discharged July 26, 2019. The policy and procedure manual stated that treatment plan updates must be completed every 15 days. The client record had completed treatment plan updates; however, treatment plan updates were completed outside the 15day policy.Client #7 was admitted into the partial hospitalization activity on January 28, 2019 and was discharged April 13, 2019. The policy and procedure manual stated that treatment plan updates must be completed every 15 days. The client record had completed treatment plan updates; however, treatment plan updates were completed outside the 15day policy.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Clinical Officer and Clinical Supervisor have reviewed the policies relating to management of treatment/rehabilitation services for clients in the partial hospital program. The following policy guidelines have been changed to increase compliance.
Initial treatment plans for partial hospital will be completed with in 7 clinical days from date of admission.
Treatment plan updates will be reviewed and completed every 30 days.
The clinical supervisor has updated staff as to the new policy and has performed an in-service with counselors to inform them of the change.
The Clinical Supervisor will perform routine chart audits to ensure compliance with the policy change. |
709.26 (a) (4) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(4) Orientation of new employees.
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Observations
The facility failed to develop a policy and procedure for the orientation of new employees.The findings were discussed with facility staff during the licensing process
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Plan of Correction
The executive leadership of the facility has met and developed an orientation protocol for all new employees at time of hire.
The Chief Executive Officer will be responsible for review of new employee orientation subsequent to department head orientation utilizing the new employee orientation checklist. The checklist will be kept upon completion in the employees training file. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in four of fourteen client records reviewed.Client #8 was admitted into the outpatient level of care on February 12, 2019 and was still active at the time of the inspection. There was documentation of billing to the funding source; however, there was no consent form on file prior to the disclosure of information.Client #9 was admitted into the outpatient level of care on March 6, 2019 and was still active at the time of the inspection. There was documentation of billing to the funding source; however, there was no consent form on file prior to the disclosure of information.Client #12 was admitted into the outpatient level of care on April 14, 2019 and was discharged August 9, 2019. There was documentation of billing to the funding source; however, there was no consent form on file prior to the disclosure of information.Client #13 was admitted into the outpatient level of care on January 2, 2019 and was discharged June 21, 2019. There was documentation of billing to the funding source; however, there was no consent form on file prior to the disclosure of informationThe findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Chief Executive Officer and Facility Director met with Admissions staff and performed an in-service on informed and voluntary consent and results of the DDAP licensing survey. Specifically ensuring a consent is reviewed and signed voluntarily by client's upon admission.
The Director of Admissions will perform weekly audits of informed consents to ensure ongoing compliance. |
709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
The facility failed to document preliminary treatment plans in two of seven partial hospitalization records reviewed.Client #1 was admitted into the partial hospitalization activity on February 19, 2019 and was active at the time of inspection.Client #2 was admitted into the partial hospitalization activity on August 7, 2019 and was active at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor had an in-service with counselor's to review the regulation on preliminary treatment plans. At this time it was identified as part of the assessment process, client and counselor will develop a preliminary treatment plan at time of assessment until such time as a more individualized comprehensive treatment plan can be created.
The Clinical Supervisor will be performing random chart audits to ensure compliance with the new procedure. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
The facility failed to provide treatment plan updates within the regulatory timeframe in one of three applicable partial hospitalization client records reviewed.Client #7 was admitted into the partial hospitalization activity on January 28, 2019 and was discharged April 13, 2019. A comprehensive treatment plan was completed on February 1, 2019 and the update was due no later than March 1, 2019. 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 policy regarding treatment plan updates has been change to reflect that of the state required 30 day review for the partial level of care.
Staff have been oriented to the procedural and policy change by the clinical supervisor and the clinical supervisor will perform periodic chart audits to ensure compliance. |
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
The facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice a week, in three of seven partial hospitalization client records reviewed.Client #1 was admitted into the partial hospitalization activity on February 19, 2019 and was active at the time of inspection. Documentation of two individual sessions per week was not completed for the week of March 17 to March 23, 2019, March 24 to March 30, 2019, March 31 to April 6, 2019, April 6 to April 14, 2019.Client #2 was admitted into the partial hospitalization activity on August 7, 2019 and was active at the time of inspection. Documentation of two individual sessions per week was not completed for the time frame of August 11 thru September 7, 2019.Client #5 was admitted into the partial hospitalization activity on January 14, 2019 and was discharged April 14, 2019. Documentation of two individual sessions per week was not completed for the time frame of January 14 thru April 14, 2019.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Some of the lack of compliance with two individual sessions were traced back to lack of attendance. However, moving forward this will be documented in the client record.
The expectation moving forward will be that the canceled no show individual session will be documented via progress note. This will be shared in an email and followed with staff on 10/14/19 by the Clinical Supervisor who will also monitor for ongoing compliance monthly.
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709.83(a) LICENSURE Client records
709.83. 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:
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Observations
The facility failed to have a complete client record that is to include progress notes and follow up in three of seven partial hospitalization client records reviewed.Client #1 was admitted into the partial hospitalization activity on February 19, 2019 and was active at the time of inspection. The facility failed to document progress notes for the client.Client #4 was admitted into the partial hospitalization activity on January 24, 2019 and was discharged February 13, 2019. The facility failed to document follow up information for the client.Client #6 was admitted into the partial hospitalization activity on June 10, 2019 and was discharged July 26, 2019. The facility failed to document follow up information for the client.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility will now utilize the alumni coordinator to perform discharge follow up duties. This will be logged in the client record. Discharge follow up in accordance with our follow up and aftercare policy. This will be in place on or before 10/15/2019.
The clinical supervisor will perform monthly chart audits to ensure compliance moving forward. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
The facility failed to include documentation of a preliminary treatment plan during the intake and admission period in two of seven outpatient client records reviewed.Client #8 was admitted into the outpatient level of care on February 12, 2019 and was still active at the time of the inspection. Client #11 was admitted into the outpatient level of care on January 2, 2019 and was discharged July 1, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has met with the counseling staff and have agreed upon to perform a preliminary treatment at time of assessment based on clinical data acquired during this process until such time as the individualized comprehensive treatment plan is developed. This process will be in place on or before 10/4/2019.
The clinical supervisor will perform monthly chart audits to ensure compliance. |
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
The facility failed to provide treatment plan updates within the regulatory timeframe in three of seven outpatient client records reviewed.Client #9 was admitted on March 6 2019 and was active at the time of inspection. A treatment plan update was completed on June 15, 2019 and the next update was due no later than July 15, 2019. However, the update was not completed until September 3, 2019.Client #12 was admitted on April 16, 2019 and was discharged August 9, 2019. A comprehensive treatment plan was completed on April 19, 2019 and a treatment plan update was due no later than June 19, 2019. However, the update was not completed at the time of inspection.Client #13 was admitted on January 2, 2019 and was discharged June 21, 2019. A comprehensive treatment plan was completed on January 3, 2019 and a treatment plan update was due no later than March 3, 2019. 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 policy regarding treatment plan updates has been change to reflect that of the state required 60 day review for the Outpatient project.
Staff have been oriented to the procedural and policy change by the clinical supervisor and the clinical supervisor will perform monthly chart audits to ensure compliance. |
709.93(a) LICENSURE Client records
709.93. 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:
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Observations
The facility failed to have a complete client record that is to include case consultation notes and follow-up information in four of seven outpatient client records reviewed.Client #11 was admitted into the outpatient level of care on January 2, 2019 and was discharged July 1, 2019.The facility failed to document case consultations.Client #12 was admitted on April 16, 2019 and was discharged August 9, 2019. The facility failed to document case consultations and follow-up information.Client #13 was admitted on January 2, 2019 and was discharged June 21, 2019. The facility failed to document case consultations, and follow-up information. Client #14 was admitted on March 18, 2019 and was discharged September 6, 2019. The facility failed to document case consultations and follow-up information. These findings were discussed with facility staff during the licensing process
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Plan of Correction
Case Consultation policy/procedure has been updated to reflect needing to be completed every 90 days and counseling staff have been updated on the change by the clinical supervisor.
The facility will now utilize the alumni coordinator to perform discharge follow up duties. This will be logged in the client record. Discharge follow up in accordance with our follow up and aftercare policy. This will be in place on or before 10/15/2019.
The clinical supervisor will perform monthly chart audits to ensure compliance with the aforementioned moving forward.
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