INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17, 2025, 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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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of administrative information, the facility failed to document an assessment of staff training needs.
Per the policy and procedure, an annual assessment of staff training needs will be completed in the third quarter of the calendar year by the Clinical Outpatient Program Director or his/her/their designee.
An assessment of staff training needs for training year January 1, 2026-December 31, 2026, was due no later than September 30, 2025; however, there was no assessment of staff training needs documented.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Outpatient Program Director or his/her designee will complete an annual staff training needs assessment for January 1, 2026 to December 31, 2026 by 12/13/2025. This assessment will document required training areas and role-specific education needs for staff.
To ensure this deficiency does not recur, the Clinical Outpatient Program Director or his/her designee will complete future assessments of individual staff training needs in the third quarter of the calendar year. The Outpatient Program Director will meet individually with each staff member by September 30th to develop and finalize training plan for the upcoming year.
The Outpatient Program Director will be responsible for ensuring the correction action is implemented.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs, the facility failed to conduct an unannounced fire drill at least once a month.
Fire drill logs were reviewed from November 2024 through October 2025. There was no fire drill conducted in January 2025 or June 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Outpatient Program Director or his/her designee will develop and implement an annual schedule that ensures fire drills are conducted once each month by 12/13/2025.
To ensure the deficiency does not recur, Outpatient Program Director will review the fire drill schedule on the 20th of each month to ensure that one has been completed.
The Outpatient Program Director will ensure the corrective action is implemented. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of administrative information, the facility failed to make an annual report available to the public. The last report on facility website was the 2023 annual report, and there was no report available for 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Milestone will develop an annual report tailored to the DDAP Program.
The Outpatient Program Director will be responsible for ensuring the corrective action is implemented.
To ensure this deficiency does not recur in the future, the Outpatient Program Director will collaborate with the Senior Director of Clinical Services to develop a program specific annual report at the beginning of the new fiscal year. |