INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2022 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(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.
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Observations
Based on a review of staff records, the facility failed to document that staff persons received TB/STD and HIV/AIDS training within the required timeframe in three of three personnel records.
Staff #3 was hired as a D/A counselor on April 17, 2017. TB/STD and HIV/AIDS was due to be completed by April 17, 2018. There was no documentation of TB/STD and HIV/AIDS in staff record #3.
Staff #4 was hired as a D/A counselor on April 18, 2017. TB/STD and HIV/AIDS was due to be completed by April 18, 2018. There was no documentation of TB/STD and HIV/AIDS in staff record #4.
Staff #5 was hired as a D/A counselor on April 18, 2017. TB/STD and HIV/AIDS was due to be completed by April 18, 2018. There was no documentation of TB/STD and HIV/AIDS in staff record #4.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the March 10, 2021 and February 3-4, 2020 annual licensing inspections.
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Plan of Correction
The Director of Quality Assurance and Compliance will provide all current staff that have not received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training with the internal curriculums approved by the Department on February 23, 2022.
All current staff will be trained in both requirements by April 29, 2022.
New staff will be trained by the training department on these requirements upon hire.
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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 document unannounced fire drills at least once per month.
The fire drill logs were requested for the period of March 2021 through January 2022. There was one fire drill documented for the month of January 2022. There were no other drills documented for the time period reviewed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 10, 2021 annual licensing inspection.
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Plan of Correction
The Clinical Services Office Manager will be responsible for completing fire drills at least once a month and maintaining a Fire Drill Log of all monthly fire drills for on-site review.
A new annual Fire Drill Summary report was developed by the Director of Quality Assurance and Compliance to document unannounced fire drills and given to the Clinical Services Office Manager for use moving forward. Fire drills have already been completed for January and February.
The Clinical Office Services Manager will sign an acknowledgement of this requirement by March 11, 2022
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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 that it obtained an informed and voluntary consent from the client for the disclosure of information contained in the client record in six of six client records.
There were no valid consents documented in client records #1, 2, 3, 4, 5 and 6 for the release of the client's information. It was confirmed that information had been sent to obtain payment for these clients for services rendered.
Client #1 was admitted on June 10, 2021 and is currently an active client. There was no signed release of information for the funding source in client record #1.
Client #2 was admitted on March 25, 2021 and is currently an active client. There was no signed release of information for the funding source in client record #2.
Client #3 was admitted on February 19, 2019 and is currently an active client. There was no signed release of information for the funding source in client record #3.
Client #4 was admitted on March 1, 2021 and discharged on July 19, 2021. There was no signed release of information for the funding source in client record #4.
Client #5 was admitted on December 7, 2020 and discharged on December 27, 2021. There was no signed release of information for the funding source in client record #5.
Client #6 was admitted on January 25, 2021 and discharged on November 3, 2021. There was no signed release of information for the funding source in client record #6.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 10, 2021 and February 3-4, 2020 annual licensing inspections.
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Plan of Correction
The Clinical Services Office Manager will mail a hard copy of the client orientation packet, which includes an informed and voluntary consent for the disclosure of information form, to all current clients for signature and document the mailing in the client's record.
No information in the client's records will be released until a valid consent form is obtained from the clients.
No new clients will be accepted into the program until April 1, 2022.
Intake Coordinators will be trained on the orientation process by April 1, 2022
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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.
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Observations
Based on a review of client records, the facility failed to document acknowledgement that clients were informed of their rights in three of three client records.
Client #1 was admitted on June 10, 2021 and is currently an active client. Client receives telehealth services. There was no documentation the client was provided with the required client rights.
Client #2 was admitted on March 25, 2021 and is currently an active client. Client receives telehealth services. There was no documentation the client was provided with the required client rights.
Client #4 was admitted on March 1, 2021 and discharged July 19, 2021. Client received telehealth services. There was no documentation the client was provided with the required client rights.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 10, 2021 and February 3-4, 2020 annual licensing inspections.
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Plan of Correction
The Clinical Services Office Manager will mail a hard copy of the client orientation packet, which includes information on client's rights, to all current clients for signature and document the mailing in the client's record.
No new clients will be accepted into the program until April 1, 2022.
Intake Coordinators will be trained on the orientation process by April 1, 2022
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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
Based on a review of client records, the facility failed to document the disclosure of the criteria for admission, treatment, completion, and discharge in three of three client records.
Client #1 was admitted on June 10, 2021 and is currently an active client. Client receives telehealth services. There was no documentation the client was provided with orientation including the criteria for admission, treatment, completion and discharge.
Client #2 was admitted on March 25, 2021 and is currently an active client. Client receives telehealth services. There was no documentation that the client was provided with orientation including the criteria for admission, treatment, completion and discharge.
Client #4 was admitted on March 1, 2021 and discharged July 19, 2021. Client received telehealth services. There was no documentation that the client was provided with orientation including the criteria for admission, treatment, completion, and discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Services Office Manager will mail a hard copy of the client orientation packet, which includes an criteria for admission, treatment, completion and discharge, to all current clients for signature and document the mailing in the client's record.
No new clients will be accepted into the program until April 1, 2022.
Intake Coordinators will be trained on the orientation process by April 1, 2022 |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation including project policies in three of three client records.
Client #1 was admitted on June 10, 2021 and is currently an active client. Client receives telehealth services. There was no documentation the client was provided with orientation including project policies.
Client #2 was admitted on March 25, 2021 and is currently an active client. Client receives telehealth services. There was no documentation the client was provided with orientation including project policies.
Client #4 was admitted on March 1, 2021 and discharged July 19, 2021. Client received telehealth services. There was no documentation the client was provided with orientation including project policies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Services Office Manager will mail a hard copy of the client orientation packet, which includes project policies, to all current clients for signature and document the mailing in the client's record.
No new clients will be accepted into the program until April 1, 2022.
Intake Coordinators will be trained on the orientation process by April 1, 2022.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document client orientation including hours of operation in three of three client records.
Client #1 was admitted on June 10, 2021 and is currently an active client. Client receives telehealth services. There was no documentation the client was provided with orientation including hours of operation.
Client #2 was admitted on March 25, 2021 and is currently an active client. Client receives telehealth services. There was no documentation the client was provided with orientation including hours of operation.
Client #4 was admitted on March 1, 2021 and discharged July 19, 2021. Client received telehealth services. There was no documentation the client was provided with orientation including hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
he Clinical Services Office Manager will mail a hard copy of the client orientation packet, which includes hours of operation, to all current clients for signature and document the mailing in the client's record.
No new clients will be accepted into the program until April 1, 2022.
Intake Coordinators will be trained on the orientation process by April 1, 2022.
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709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation including fee schedules in three of three client records.
Client #1 was admitted on June 10, 2021 and is currently an active client. Client receives telehealth services. There was no documentation the client was provided with orientation including fee schedules.
Client #2 was admitted on March 25, 2021 and is currently an active client. Client receives telehealth services. There was no documentation the client was provided with orientation including fee schedules.
Client #4 was admitted on March 1, 2021 and discharged July 19, 2021. Client received telehealth services. There was no documentation the client was provided with orientation including fee schedules.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Services Office Manager will mail a hard copy of the client orientation packet, which includes a fee schedule, to all current clients for signature and document the mailing in the client's record.
No new clients will be accepted into the program until April 1, 2022.
Intake Coordinators will be trained on the orientation process by April 1, 2022.
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to document client orientation including services provided in three of three client records.
Client #1 was admitted on June 10, 2021 and is currently an active client. Client receives telehealth services. There was no documentation the client was provided with orientation including services.
Client #2 was admitted on March 25, 2021 and is currently an active client. Client receives telehealth services. There was no documentation the client was provided with orientation including services provided.
Client #4 was admitted on March 1, 2021 and discharged July 19, 2021. Client received telehealth services. There was no documentation the client was provided with orientation including services provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Services Office Manager will mail a hard copy of the client orientation packet, which includes services provided, to all current clients for signature and document the mailing in the client's record.
No new clients will be accepted into the program until April 1, 2022.
Intake Coordinators will be trained on the orientation process by April 1, 2022
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to treatment in three of three client records.
Client #1 was admitted on June 10, 2021 and is currently an active client. Client receives telehealth services. There was no documentation of a consent to treatment.
Client #2 was admitted on March 25, 2021 and is currently an active client. Client receives telehealth services. There was no documentation of a consent to treatment.
Client #4 was admitted on March 1, 2021 and discharged July 19, 2021. Client received telehealth services. There was no documentation of a consent to treatment.
These findings were reviewed with facility staff during the licensing process.
The is a repeat citation from the March 10, 2021 annual licensing inspection.
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Plan of Correction
The Clinical Services Office Manager will mail a hard copy of the client orientation packet, which includes a written consent to treatment, to all current clients for signature and document the mailing in the client's record.
Verbal consent will be obtained from each current client at their next scheduled appointment and documented in the client record.
No new clients will be accepted into the program until April 1, 2022.
Intake Coordinators will be trained on the orientation process by April 1, 2022. |
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 five of six client records.
Client #1 was admitted on June 10, 2021 and is currently an active client. The last treatment plan update was dated July 14, 2021.
Client #2 was admitted on March 25, 2021 and is currently an active client. The last treatment plan update was dated May 27, 2021.
Client #4 was admitted on March 1, 2021 and discharged on July 19, 2021. There was a treatment plan developed March 17, 2021. A treatment plan update was required to be completed by May 17, 2021. The treatment plan update was documented on July 13, 2021.
Client #5 was admitted on December 7, 2020 and discharged on December 27, 2021. There was a treatment plan developed March 8, 2021. A treatment plan update was required to be completed by May 8, 2021. The treatment plan update was documented on July 19, 2021 there were no other treatment plan updates documented.
Client #6 was admitted on January 25, 2021 and discharged on November 3, 2021. A treatment plan was documented on May 25, 2021. A treatment plan update was due to be completed by July 25, 2021 and September 25, 2021. The only other treatment plan update was documented on November 3, 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 10, 2021, February 3-4, 2020 and January 4, 2019 annual licensing inspections.
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Plan of Correction
The Director of Outpatient will work the Facility Director to develop treatment planning timelines to meet the 60-day review and update requirement. Treatment and rehabilitation plans will be reviewed and updated at least every 60 days moving forward.
No new clients will be accepted into the program until April 1, 2022.
Clinicians will be trained on treatment planning timeframe expectations by April 1, 2022.
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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 at least every 90 days in six of six client records.
Client #1 was admitted on June 10, 2021 and is currently an active client. There were no case consultations documented in client record #1.
Client #2 was admitted on March 25, 2021 and is currently an active client. There was one case consultation documented dated August 25, 2021. There were no other case consultations documented in client record #2.
Client #3 was admitted on February 19, 2019 and is currently an active client. There were no case consultations documented in client record #3.
Client #4 was admitted on March 1, 2021 and discharged on July 19, 2021. There were no case consultations documented in client record #4.
Client #5 was admitted on December 7, 2020 and discharged on December 27, 2021. There were no case consultations documented in client record #5.
Client #6 was admitted on January 25, 2021 and discharged on November 3, 2021. There were no case consultations documented in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Outpatient will work with the Facility Director to develop a case consultation procedure between two or more staff. The case consultation meeting will be documented in the client record.
A dedicated note will be developed in the electronic health record, labeled "Case Consultation Note" to document this meeting by April 1, 2022.
No new clients will be accepted into the program until April 1, 2022.
Clinicians will be trained on the case consultation procedures by April 1, 2022.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up within 7 days of discharge, per agency policy, in three of three client records.
Client #4 was admitted on March 1, 2021 and discharged on July 19, 2021. There was no follow up documented in client record #4.
Client #5 was admitted on December 7, 2020 and discharged on December 27, 2021. There were no follow up documented in client record #5.
Client #6 was admitted on January 25, 2021 and discharged on November 3, 2021. There were no follow up documented in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Outpatient will work with the Facility Director to develop a client follow-up packet which includes follow-up information.
The Clinical Services Office Manager will mail the packet to the client after discharge. A copy of the letter will be placed in the client's record.
No new clients will be accepted into the program until April 1, 2022.
Clinicians will be trained on client follow-up procedures by April 1, 2022.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, staff training records and fire drill logs, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for treatment plan updates were submitted and approved by the Department for the March 10, 2021, February 2-4, 2020 and January 4, 2019 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the January 31, 2022 licensing inspection.
Plans of correction for client rights were submitted and approved by the Department for the March 10, 2021 and February 2-4, 2020 annual licensing inspections. Client rights were again found to be a deficiency in the January 31, 2022 licensing inspection.
Plans of correction for a consent to release information to the funding source were submitted and approved by the Department for the March 10, 2021 and February 2-4, 2020 annual licensing inspections. Consents to release information to the funding source were again found to be a deficiency in the January 31, 2022 licensing inspection.
Plans of correction for HIV/AIDS and TB/STD training were submitted and approved by the Department for the March 10, 2021 and February 2-4, 2020 annual licensing inspections. TB/STD and HIV/AIDS training was again found to be a deficiency in the January 31, 2022 licensing inspection.
A plan of correction for fire drills was submitted and approved by the Department for the March 10, 2021 annual licensing inspection. Fire Drills were again found to be a deficiency in the January 31, 2022 licensing inspection.
A plan of correction for client consent to treatment was submitted and approved by the Department for the March 10, 2021 annual licensing inspection. Client consent to treatment was again found to be a deficiency in the January 31, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The agency hired a Director of Quality Assurance and Compliance on February 7, 2022, who will be responsible for maintaining compliance standards of Chapter 28 and monitoring and implementing all Plans of Correction with the Department. This position is a new role within the agency. |