INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 19, 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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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
Based on a review of personnel and training records, the facility failed to document fire extinguisher training, upon staff employment, in four of four applicable personnel records.
Staff #1 was hired on February 28, 2022. There was no documentation of fire extinguisher training in personnel record #1.
Staff #2 was hired on March 28, 2022. There was no documentation of fire extinguisher training in personnel record #2.
Staff #4 was hired on June 6, 2022. There was no documentation of fire extinguisher training in personnel record #4.
Staff #5 was hired on October 15, 2022. There was no documentation of fire extinguisher training in personnel record #5.
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 added a "Fire Safety and Emergency Preparedness Training" to the annual Outpatient Training Plan for 2023 for all staff to complete by the corrective action date, which includes fire extinguisher training. The training will be documented in the organization's learning management system.
The "Fire Safety and Emergency Preparedness" training will be added as a required part of the Outpatient Orientation Training Plan for all new hires to complete during their orientation period.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel and training records, the facility failed to document emergency procedures training, upon staff employment, in four of four applicable personnel records.
Staff #1 was hired on February 28, 2022. There was no documentation of emergency procedures training in personnel record #1.
Staff #2 was hired on March 28, 2022. There was no documentation of emergency procedures training in personnel record #2.
Staff #4 was hired on June 6, 2022. There was no documentation of emergency procedures training in personnel record #4.
Staff #5 was hired on October 15, 2022. There was no documentation of emergency procedures fire extinguisher training in personnel record #5.
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 added a "Fire Safety and Emergency Preparedness Training" to the annual Outpatient Training Plan for all staff to complete by the corrective action date. The training will be documented in the organization's learning management system.
The Director of Quality Assurance and Compliance or their designee will train all outpatient staff on Milestone's Emergency Response Plan specific to their site location.
The "Fire Safety and Emergency Preparedness" training will be added as a required part of the Outpatient Orientation Training Plan for all new hires to complete during their orientation period
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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 document annual performance evaluations in one of one personnel records.
Staff #3 was hired on March 14, 2013. There was no annual performance evaluation documented for 2022 in personnel record #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Outpatient Program Director and the Outpatient Clinical Supervisor will complete annual written individual staff performance evaluations with each staff member by the corrective action date.
Human Resources will incorporate Outpatient program management into the evaluation reminder process to ensure performance evaluations are completed for all outpatient staff annually.
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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
Based on a review of client records, the facility failed to document a signed consent to release information for the funding source in two of three client records.
Client #2 was admitted on September 7, 2022 and discharged on December 9, 2022. There was no signed consent to release information to the funding source in client record #2. It was confirmed that the facility did receive funds for this client.
Client #3 was admitted on March 30, 2022 and discharged on June 2, 2022. There was no signed consent to release information to the funding source in client record #3. It was confirmed that the facility did receive funds for this client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward, clinicians will obtain all required releases of information for new clients at the time of the intake assessment, whether in person or via telehealth.
The Director of Quality Assurance and Compliance will review active client charts monthly for 60 days to ensure releases of information are being obtained.
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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
Based on a review of client records, the facility failed to document treatment plan updates at least every 60 days in one of three client records.
Client #1 was admitted on January 20, 2022 and discharged on November 10, 2022. Client #1 had a treatment plan update documented on August 17, 2022. The next treatment plan update was due to be completed by October 17, 2022. The treatment plan update was completed on November 10, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient Clinical Supervisor or their designee will work with clinicians to ensure all treatment plans for active substance use disorder clients are updated according to regulatory standards and will review treatment plan expiration dates during individual supervision with each clinician for 60 days.
The Director of Quality Assurance and Compliance and BH Systems Manager developed an updated face sheet for the outpatient program on the electronic health record (EHR) that includes a "Treatment Plan Expiration Date" module to support clinicians in updating treatment plans.
The BH Systems Manager implemented a new treatment plan specific to substance use disorder clients that includes 60-day treatment plan alerts to support clinicians in updating plans.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations every 90 days, as per agency policy, in one of three client records.
Client #1 was admitted on January 20, 2022 and discharged on November 10, 2022. Case consultations were due to be completed by April 20, July 20 and October 20, 2022. One case consultation was documented on September 23, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Outpatient Supervisor or their designee will complete case consultations every 90 days. All clients will be reviewed and updated in the next quarter.
The Clinical Outpatient Supervisor will create an internal tracking process to ensure case consultations are completed within regulatory standards. This internal tracking process will be monitored by the Director of Quality Assurance and Compliance for 90 days.
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