INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6, 2023 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of facility records, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures for the year 2023. Some facility policy and procedures did not contain all necessary components to meet regulation standards. These policies include 704.11 Staff development program and 709.26 Personnel management.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Assurance and Compliance will develop a sign-off sheet for the Project Director to sign annually. The Project Director will review and sign the updated written manual delineating project policies and procedures including 704.11 Staff Development Program and 709.26 Personnel Management. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to offer a copy of a consent form to the client in one of one record.Client #5 was admitted to the outpatient level of care on October 19, 2023 and was active at the time of review. Client #5 ' s record contained a release of information dated for October 17, 2023, 2023. No evidence that a copy of the consent form was offered to the client was provided.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Assurance and Compliance will complete training with Outpatient staff on completing Releases of Information which will include the requirement of offering a copy of a consent form to the client. The Project Director or their designee will complete quarterly chart audits to review the accurate completion of Releases of Information. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of facility policy and procedure, as well as client records, the facility failed to develop written policies and procedures on client rights and document written acknowledgement by clients that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in seven of seven records. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director and Director of Quality Assurance and Compliance will review and update the agency's Nondiscrimination Policy to include that the project may not discriminate in the provision of services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, and or religion. Documented written acknowledgement by clients will be included in the facility's Bill of Rights located in the Intake Packet. |