INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3 - 4, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The facility failed to ventilate both second floor bathrooms by exhaust fan or window based on a physical plant inspection conducted with the project/facility director and clinical supervisor on January 3, 2019 at approximately 2:30 PM.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The property owner has replaced both fans. Fans are now functional. Milestone operates a Health and Safety Committee that inspects all facilities bi-annually for deficiencies. A safety inspection checklist is used and maintained by the committee. Bathroom exhaust fans have been added to the checklist. The Facility Director will be responsible for ensuring that the Health and Safety Committee provides inspection lists to be maintained at the program offices. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document that staff were instructed in the use of the fire extinguisher upon staff employment in five of five personnel records reviewed on January 4, 2019.
Employee # 1 was employed by the D/A facility on April 1, 2018.
Employee # 2 was employed by the D/A facility on April 1, 2018.
Employee # 3 was employed by the D/A facility on April 1, 2018.
Employee # 4 was employed by the D/A facility on March 26, 2018.
Employee # 5 was employed by the D/A facility on April 1, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director obtained new training material on the use of fire extinguishers. Material will be reviewed during the next group supervision. All staff receiving the training will sign an acknowledgment form, which will be added to the personnel file. This training has been added to the list of orientation items for new employees. |
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
The facility failed to document unannounced fire drills at least once a month based on a review of fire drill records on January 3, 2019.
No fire drills were conducted for February, March and December 2018.
The fire drill records for April - November 2018 did not include documentation of the exit route used, number of persons in the facility at the time of the drill, problems encountered and whether or not the fire alarm or smoke detector was operative.
In addition, the facility failed to document that all personnel were trained to perform assigned tasks in emergencies based on a review of personnel records # 1, 2, 3, 4 and 5.
The findings were reviewed with facility staff during the licensing process.
The monthly fire drill citation is a repeat citation from the 2018 licensing inspection.
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Plan of Correction
Project Director has developed a schedule for fire drills for the entire year. This schedule will be kept confidential to ensure that drills meet the requirement of being unannounced. The Project Director will provide the monthly date to a designee one week in advance for coordination. This new system will ensure that each month is accounted for. Additionally, a new fire drill log has been adopted that contain all necessary required elements.
The Project Director will maintain all fire drill records. They will be monitored monthly as they are performed, and then again annually as part of our overall Quality Assurance plan.
Milestone has an emergency protocol for each facility. All staff will be retrained on the emergency and evacuation protocol for this facility. We have created an acknowledgement that they will sign. This acknowledgement will be maintained in their personnel file. Personnel files are audited and maintained by Human Resources regularly |
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
The facility failed to document a written, informed and voluntary consent from the client for the disclosure of information contained in the client record in four of four client records reviewed on January 3, 2019.
The facility released the name and diagnosis of the client to the funding entity without the written consent of the client in the following records:
Client # 1 was admitted July 18, 2018.
Client # 2 was admitted April 20, 2018.
Client # 3 was admitted May 24, 2018.
Client # 4 was admitted April 17, 2018.
The facility utilized a consent to release information form dated January 14, 2015. The consent form included the statement "In order to revoke this authorization, I understand I must revoke it in writing to Milestone." The facility failed to adhere to the requirements in the federal confidentiality regulations by requiring the client to revoke the consent in writing in client records # 1, 3 and 4.
The consent form also required a parent signature for minor clients. This is in violation of the drug and alcohol laws and regulations pertaining to minors (71 P.S. 1690.112 (a)(b) and 42 CFR Part 2, Subpart B, 2.14 (b).
The consent form allowed for the client's verbal consent to release information. State and federal confidentiality regulations require the consent to release information to include the written signature of the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director reviewed consent form and revised it to be compliant with State and Federal confidentiality regulations. No client information will be released without obtaining a written, informed and voluntary consent from the client. All existing clients will be presented with the new consent form for signature at their next appointment. New consent form has been added to intake packet to ensure that new clients are presented with this consent. Also, the process for transferring a client from another existing program into the outpatient D&A program has been reviewed. Staff who are tasked with this transfer have been informed of the need to complete this consent with all transferring clients.
Consent Forms have been added to the Outpatient chart audit checklist. The Project Director will ensure that charts are audited. Currently, random chart audits are performed monthly. Chart audit records will be maintained at the facility. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in four of four client records reviewed on January 3, 2019.
There was no documentation that the client was informed of the following rights: a client shall retain civil rights and liberties except as provided by statute, the project may not discriminate in the provision of services on the basis of race, creed and color, the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if the director determines the information may be detrimental and reasons for removing sections shall be documented in the record and the right to submit rebuttal data or memoranda to their own records in client records # 1, 2, 3 and 4.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director updated the client rights form. The new form contains all required elements. This form is specific to outpatient D&A services at Milestone. This form requires the signature of a client and a witness. A signed copy is maintained in the client record. This form is currently on the chart audit checklist. The form has been added to the intake packet to ensure that all clients are provided with this information. Staff who are responsible for the transfer of clients from other programs into outpatient D&A have been informed of the need to provide the new client rights information to all clients transferring into the program.
The Project Director is responsible for ensuring that charts are audited for compliance. Currently, random chart audits occur monthly. Chart audit results are maintained at the facility. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
The facility failed to document the disclosure to the client of criteria for admission, treatment, completion and discharge in four of four client records reviewed on January 3, 2019.
Client # 1 was admitted July 18, 2018.
Client # 2 was admitted April 20, 2018.
Client # 3 was admitted May 24, 2018.
Client # 4 was admitted April 17, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director updated the Consent to Participate form. On this form, the client acknowledges the following: "I have been informed of the criteria for admission, treatment completion and discharge." This information had previously been provided to all clients entering our outpatient program, but there was not an official acknowledgment from the client. This information will continue to be provided to the client by either the intake clinician or counselor conducting the intake.
The Consent to Participate form is on the chart audit checklist. The Project Director will be responsible for ensuring that charts are audited. Currently, random chart audits occur monthly. Record of chart audits is maintained at the facility. |
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
The facility failed to document an individual treatment plan including the type of treatment and rehabilitation services in four of four client records reviewed on January 3, 2019.
Client # 1 was admitted July 18, 2018. The individual treatment plan was documented July 18, 2018.
Client # 2 was admitted April 20, 2018. The individual treatment plan was documented April 20, 2018.
Client # 3 was admitted May 24, 2018. The individual treatment plan was documented June 6, 2018.
Client # 4 was admitted April 17, 2018. The individual treatment plan was documented May 10, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure that all staff are properly trained in the provision of treatment planning. This re-training will occur in group supervision and individual supervision. The training will include time frames for both initial plan and review, modalities (type of treatment), measurability, required signatures, and general philosophy of treatment.
Re-training has already begun.
This training will be documented in individual and group supervision notes.
The Project Director will be responsible for ensuring that chart are audited. Treatment Plans are always reviewed for compliance at audit. Currently, random chart audits occur monthly. Record of chart audits are maintained at the facility. |
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.
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Observations
The facility failed to document a treatment plan update at least every 60 days in four of four client records reviewed on January 3, 2019.
Client # 1 was admitted July 18, 2018. The individual treatment plan was documented July 18, 2018. Treatment plan updates were documented August 17 and November 13, 2018.
Client # 2 was admitted April 20, 2018. The individual treatment plan was documented April 20, 2018. Treatment plan updates were documented June 11, July 17 and October 23, 2018.
Client # 3 was admitted May 24, 2018. The individual treatment plan was documented June 6, 2018. Treatment plan updates were documented September 13 and October 1, 2018.
Client # 4 was admitted April 17, 2018. The individual treatment plan was documented May 10, 2018. Treatment plan updates were documented July 12 and November 8, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure that all staff are properly trained in the provision of treatment planning. This re-training will occur in group supervision and individual supervision. The training will include time frames for both initial plan and review, modalities (type of treatment), measurability, required signatures, and general philosophy of treatment.
Re-training has already begun.
This training will be documented in individual and group supervision notes.
The Project Director will be responsible for ensuring that chart are audited. Treatment Plans are always reviewed for compliance at audit. Currently, random chart audits occur monthly. Record of chart audits are maintained at the facility. |