INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 10, 2021 by staff from the 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.
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on the review of personnel records, the facility failed to ensure staff received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the required timeframe, in two of two records. Employee # 1 was hired as the project/facility director on April 1, 2018. The required trainings were due to be completed by April 1, 2020. There was no documentation the training had been completed. Employee # 3 was hired as a counselor on April 1, 2018. The training was due to be completed by April 1, 2019. There was no documentation the training had been completed. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the February 3-4, 2020 inspection.
|
Plan of Correction
Employees #1 and 3 will be both be scheduled at the next available virtual trainings for HIV and TB/STD. Goal date for completion will be June 30, 2021. All other training logs will be reviewed by the project director to ensure that required trainings have been obtained by all project staff within required timeframes. |
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.
|
Observations
Based on the review of the fire drill logs, the facility failed to document that fire drills were conducted at least once a month. The fire drill logs were reviewed were from March 2020 to February 2021. There were no fire drills documented for the time period reviewed. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Fire drills were not completed due to a lack of understanding regarding COVID policies. Fire drills have been restarted and will be completed monthly. If no one is present in the building due to the remote work being performed by project staff, the project director or delegate will ensure that a fire drill is still completed, regardless of the presence of people in the building. |
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.
|
Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client in three of three records reviewed. Client records # 1, 2 and 3 did not document a release of information for the third-party payor. Information was released to the third-party payor. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the February 3-4, 2020 and the January 3-4, 2019 inspections.
|
Plan of Correction
A specific task list has been added to intake protocols which includes ROI for third party payers. Additionally, the intake script has been amended to include informing clients that we cannot provide service without the completion of said document. We are also developing an electronic ROI that is compliant with confidentiality laws to ensure greater ease of obtaining signatures on ROIs. The 3 records that were reviewed have been contacted and made aware of the need to complete the ROI prior to their next appointment. Project Director will monitor this task. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
|
Observations
The facility failed to document written acknowledgment by the client that they were notified of their rights in three of three client records. Client records # 1, 2 and 3 did not document written acknowledgement that the clients were informed of their rights. These findings were reviewed with faciity staff during the licensing inspection.This is a repeat citation from the February 3-4, 2020 inspection.
|
Plan of Correction
All three clients have been contacted and made aware of the need to sign a client rights acknowledgement. Project staff have been reminded of the need to ensure that this document is both signed and given to all clients. All clients are provided copies of their rights, however, signed acknowledgements have not consistently made it into the client record. In order to improve compliance with obtaining signed client rights acknowledgements, this form will be added to our list of E-Signature documents. Document addition will be completed by May 31, 2021. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on the review of client records, the facility failed to document a consent to treatment in one of three records. Client # 2 was admitted on January 22, 2021 and is still an active client. There was no documentation of a consent to treatment. These findings were reviewed with facility staff during the licensing process,
|
Plan of Correction
Milestone is currently expanding it's use of compliant, E-Signature software to mitigate the challenges of obtaining signed documents for those receiving telehealth services. Consent to treatment form has been added to our list of available E-Signature forms. Client#2 has been contacted and signature will be obtained before the next service is provided. Project Director will be responsible for ensuring that all signed forms are reviewed and uploaded to the EHR or placed in the client record. |
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.
|
Observations
Based on the review of client records, the facility failed to update the treatment and rehabilitation plan at least every 60 days in one of three client records. Client # 1 was admitted on November 19, 2020. An update was due to be completed by February 21, 2021. There was no documentation the update had been completed. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the February 3-4, 2020 and the January 3-4, 2019 inspections.
|
Plan of Correction
Procedure for completion of treatment plans updates has been retrained with the project team during group supervision time. Team was reminded of the need to complete the treatment plan updates without the client if not available. Alert system in the EHR was investigated to ensure that clinicians get timely alerts when treatment plans updates are due. Alert system is functioning properly. Staff adherence to this policy will be evaluated by supervisor in individual supervision and documented in supervision notes. |