INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Milestone Centers, Inc. 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 personnel records, the facility failed to provide an annual written individual staff performance evaluation in one of one applicable record.
Staff #3 was hired as a counselor on July 19, 2022, and was still in that position at the time of inspection. The last annual performance evaluation for staff #3 was completed in April 2023 and the next one due April 2024. There was no 2024 evaluation in staff #3 ' s record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The staff member that was missing a performance evaluation was presented a performance evaluation for development and review on 2/13/2025 to be finished and signed by 2/17/2025. This has been completed.
To ensure that all employees are given a performance evaluation annually the Outpatient Supervisor will develop and monitor when the performance evaluation is given, and then complete it every year thereafter using a excel document to show dates completed and next review by date, Outpatient supervisor will alert staff of need to complete based off of date of last evaluation.
The Outpatient Supervisor will ensure the corrective action plan is completed by having an annual performance plan completed on all staff in their individual supervision meeting.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of five applicable discharged records.
The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 30 days.
There was no follow up information documented in client records #3, 5 and 6.
Client #3 was admitted on October 25, 2023, and was discharged on June 5, 2024.
Client #5 was admitted on October 17, 2023, and was discharged on May 27, 2024.
Client #6 was admitted on May 6, 2019, and was discharged on April 19, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The deficiency relates to an inactive client chart. The program is currently not capable of seeing new clients due to lack of staff. The follow up note is already in the system and if/when the program reopens it will be used to document all communications with the client within 30 days after they are discharged.This procedure witll be discussed with all staff as part of their new hire onboarding.
All staff will be shown where the follow up document is, shown how to call and speak with the client to check in on how they are doing, then provide documentation about how the client is doing since being discharged from the program within 30 days.
The Outpatient Supervisor, Director, or Senior Director will alert the staff of the follow up document and the need for the staff to reach out to the person to follow up after they have discharged from the program.
The follow up form will be used once the program has started back up to reach out and check on how the client is doing after they have been discharged.
The follow up document will be used when all clients are discharged from the program moving forward. The Senior Director will review the Procedure for this by March 14th, 2025
Outpatient supervisor, Director, or Senior director will complete random monthly audits of chart to check that this is staying compliant.
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