INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on February 12, 2026 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 Limited Liability Company 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an annual individual training plan for each employee, with the plan having input from both the employee and their supervisor in one of five applicable personnel records reviewed.Employee # 3 was hired as a counselor on November 17, 2025. The individual training plan, documented in December 2025 did not include documentation that it was developed with input from both the employee and the supervisor.This is a repeat citation from the September 4, 2025 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 was hired in November and was given an individual training plan. Employee #3 did not sign and was given multiple notifications and reminders by higher up to get this completed. Unfortunately this was one of many things that this employee did not do in a timely manner and therefore is no longer employed with our company. Due to this we are unable to fix her individual training plan. The Lead Counselor has been making sure that the individual training plans are being done correctly |
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 personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training, during the facility's January 1, 2025 through December 31, 2025 training year, in one of one applicable personnel records reviewed.Employee # 2 was hired as a lead counselor on May 1, 2021. The personnel record documented 19 hours of training received during the training year reviewed. This is a repeat citation from the September 4, 2025 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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. Lead Counselor and Office manager has been put in charge of this and will then 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 staff may be held to disciplinary measures.
Employee #2 was spoken to about her hours not being completed in the time frame from January 1 to December 31. Employee #2 was under the impression that her hours were suppose to be completed within the year of her hired date. Employee #2 understands that it starts in January and has already signed up to complete CEUS. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor assistant completed 30 clock hours of annual training, after the first year in the position, in one of one applicable personnel record reviewed. Employee #5 was hired as a counselor assistant on December 21, 2021. At the time of the inspection, there were 12 clock hours of training documented in the personnel record during the December 21, 2024 through December 21, 2025 training year.This is a repeat citation from the July 26, 2024 and September 4, 2025 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
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. The
Lead Counselor and Office manager have been put in charge of this and will 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 staff may be held to disciplinary measures.
Employee #5 was notified about their CEU hours not being documented. This was an oversight on the employee not giving CEUs completed to staff. This has been rectified. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in one of fourteen client records reviewed.Client # 7 was admitted to the partial hospitalization activity on October 31, 2025 and was discharged on November 13, 2025. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. This is a repeat citation from the September 4, 2025 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All consents to release information will be documented correctly making sure that all information is documented including the name of the person, agency, or organization to whom the disclosure is made to. The counselor or counselor assistant will be in charge of checking those releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the director as well.
All charts have been audited by Clinical Director and notified clinical team which consents to release information forms needed to be updated and put any information necessary to make the releases compliant.
Client #7 has been discharged so unable to update the client's ROI. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in two of fourteen client records reviewed. Client # 6 was admitted to the partial hospitalization activity on October 16, 2025 and was discharged on November 28, 2025. The release of information form to a referral source was signed by the client on October 16, 2025; however, the release form did not include the specific information to be disclosed. Client # 11 was admitted to the outpatient activity on October 15, 2025 and was discharged on November 7, 2025. The release of information form to a referral source was signed by the client on October 15, 2025; however, the release form did not include the specific information to be disclosed. This was a repeat citation from the July 26, 2024 and September 4, 2025 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All consents to release information will document the specific information to be disclosed on consent and release information forms.
The counselor or counselor assistant will hold the responsibility to check said releases of clients on their caseload and will fix it with client if any information is missing. It will also be checked by the lead therapist for review.
Lead therapist has been going into charts to make sure that all consents have the specific information in the consent form.
Client #6 has been discharged so unable to update ROI to include specific information to be disclosed.
Client #11 client has been discharged so unable to update ROI to include specific information to be disclosed |
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 in one of one applicable client record reviewed.Client # 11 was admitted to the outpatient activity on October 15, 2025 and was administratively discharged on November 7, 2025. There was no documentation in the record indicating the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project. This is a repeat citation from the October 3, 2023, July 26, 2024, and September 4, 2025 annual licensing renewal inspections. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Due to client #11 being discharged in November 2025 unfortunately this client was not given a proper notification of their involuntarily discharge. This client was assigned to a therapist who was new and did not follow our protocols. This therapist is no longer with the company.
All clinical staff has been given an updated training by the Clinical Director at their clinical meeting on 2/25/26. 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.
Clinical Director provided a training on 2/25/26 during staff meeting to the clinical team. The clinical director will make sure that this is being done by chart audits that go out every week on Monday which includes discharge clients. Clinical staff will be notified if chart is out of compliance. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. 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 client records, the facility failed to ensure an individual treatment and rehabilitation plan was documented and developed with the client in three of six applicable client records reviewed. The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 10 days of admission. Client # 2 was admitted to the partial hospitalization activity on January 12, 2026 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented in the record as of the date of the inspection. Client # 4 was admitted to the partial hospitalization activity on November 21, 2025 and was discharged on February 2, 2026. There was no individual treatment and rehabilitation plan documented in the record as of the date of the inspection. Client # 5 was admitted to the partial hospitalization activity on December 24, 2025 and was discharged on February 2, 2026. There was no individual treatment and rehabilitation plan documented in the record as of the date of the inspection. This is a repeat citation from the July 26, 2024 and September 4, 2025 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward during the weekly audit report that the Clinical Director sends out it will let the clinicians know if their treatment plans have been or not been done in the timely manner within 10 days of being admitted. If the treatment plan is not done in a timely manner staff will have disciplinary action.
All clinical staff has been given an updated training by the Clinical Director at their clinical meeting on 2/25/26 on treatment planning and how this is an essential part of the client's treatment that needs to be created with the client and counselor/counselor assistant. The treatment plan needs to be developed within 10 days of intake. The initial treatment plan shall be completed day of intake.
Client #2 chart has been updated and there is a treatment plan in place
Client #4 has been discharged so unable to update the chart. The therapist who was assigned to his client knew from audits that the client was missing treatment plan and did not update the chart. This therapist is no longer employed with company.
Client #5 has been discharged so unable to update the chart. The therapist who was assigned to his client knew from audits that the client was missing treatment plan and did not update the chart. This therapist is no longer employed with company. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 client records, the facility failed to ensure an individual treatment and rehabilitation plan was documented and developed with the client in four of seven applicable client records reviewed. The facility policy and procedure manual stated that the individual treatment and rehabilitation plan is to be completed within 10 days of admission. Client # 8 was admitted to the outpatient activity on November 6, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by November 16, 2025; however, the plan was not completed until December 2, 2025.Client # 9 was admitted to the outpatient activity on November 26, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by December 6, 2025; however, the plan was not completed until December 29, 2025.Client # 11 was admitted to the outpatient activity on October 15, 2025 and was discharged on November 7, 2025. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection. Client # 13 was admitted to the outpatient activity on November 3, 2025 and was discharged on January 12, 2026. There was no individual treatment and rehabilitation plan documented in the record at the time of the inspection. This is a repeat citation from the July 26, 2024 and September 4, 2025 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward during the weekly audit report that the Clinical Director sends out it will let the clinicians know if their treatment plans have been or not been done in the timely manner within 10 days of being admitted. If the treatment plan is not done in a timely manner staff will have disciplinary action.
All clinical staff has been given an updated training by the Clinical Director at their clinical meeting on 2/25/26 on treatment planning and how this is an essential part of the client's treatment that needs to be created with the client and counselor/counselor assistant. The treatment plan needs to be developed within 10 days of intake. The initial treatment plan shall be completed day of intake.
Client #8 was assigned to a therapist who did not follow policy and procedures at our company and therefore is no longer with us.
Client #9 was assigned to a therapist who did not follow policy and procedures at our company and therefore is no longer with us.
Client #11 has been discharged and unable to update the client chart.
Client #13 has been discharged and unable to update the client chart. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of five applicable client records reviewed.Client # 8 was admitted to the outpatient activity on November 6, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 2, 2025, but the type and frequency of the treatment and rehabilitation services provided was not included in the treatment plan.Client # 9 was admitted to the outpatient activity on November 26, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 29, 2025, but the type and frequency of the treatment and rehabilitation services provided was not included in the treatment plan.Client # 10 was admitted to the outpatient activity on January 14, 2026 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 20, 2026, but the type and frequency of the treatment and rehabilitation services provided was not included in the treatment plan.This is a repeat citation from the July 26, 2024 and September 4, 2025 annual licensing inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff has been given an updated training by the Clinical Director at their clinical meeting on 2/25/26 on how to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan. The Clinical Director will audit charts and send out a report and let clinical staff know if treatment plans need to be corrected.
Client #8, #9 and #10 treatment plans have all been updated to include the type and frequency of treatment and rehabilitation services. |
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 previously approved by the Department. Plans of correction for failing to document the specific information to be disclosed on consent to release information forms were submitted and approved by the Department for the July 26, 2024, and September 4, 2025 annual licensing inspections. Failing to document the specific information to be disclosed on consent to release information forms was again found to be a deficiency during the February 12, 2026 provisional license follow-up inspection.Plans of correction for failing to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project were submitted and approved by the Department for the September 15, 2022, October 3, 2023, July 26, 2024, and September 4, 2025 annual licensing inspections. Failing to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project was again found to be a deficiency during the February 12, 2026 provisional license follow-up inspection.Plans of correction for failing to document and develop an individual treatment and rehabilitation plan for the partial hospitalization activity were submitted and approved by the Department for the July 26, 2024, and September 4, 2025 annual licensing inspections. Failing to document and develop an individual treatment and rehabilitation plan for the partial hospitalization activity was again found to be a deficiency during the February 12, 2026 provisional license follow-up inspection.Plans of correction for failing to document and develop an individual treatment and rehabilitation plan for the outpatient activity were submitted and approved by the Department for the July 26, 2024, and September 4, 2025 annual licensing inspections. Failing to document and develop an individual treatment and rehabilitation plan for the outpatient activity was again found to be a deficiency during the February 12, 2026 provisional license follow-up inspection.Plans of correction for failing to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan were submitted and approved by the Department for the July 26, 2024, and September 4, 2025 annual licensing inspections. Failing to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan was again found to be a deficiency during the February 12, 2026 provisional license follow-up inspection.Plans of correction for failing to ensure each counselor assistant, after one year in the position, completed 30 clock hours of annual training were submitted and approved by the Department for the July 26, 2024, and September 4, 2025 annual licensing inspections. Failing to ensure each counselor assistant, after one year in the position, completed 30 clock hours of annual training was again found to be a deficiency during the February 12, 2026 provisional license follow-up inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan of corrections were not all followed up on from previous audits. This has been addressed with the CEO, Clinical Director, lead Counselor and Operations manager. This was also addressed in clinical meeting on 2/25/26.
There will be consequences moving forward if clinical staff is not able to comply with having their charts stay in compliance.
Clinical Director will be going over trainings during staff meetings once a month on issues that occurred during this and previous corrective action plans to ensure this does not reoccur.
Clinical Director also sends out a weekly chart audit. |