INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on July 18, 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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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on each consent to release information in one of one client records.
Client #3 was admitted on April 9, 2014 and is still an active client. Client #3 signed a consent to release information to a funding source on April 26, 2022. This consent to release information did not include an accurate purpose of disclosure. It stated, "continued of care."
These findings were reviewed with facility staff throughout the licensing process.
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Plan of Correction
Outpatient Program management will complete a training with all program staff on Releases of Information that includes how to document the purpose of disclosure accurately by November 1, 2022.
Quarterly chart reviews of D&A clients will be completed by Outpatient program management to ensure Releases of Information are being documented appropriately.
The Director of Quality Assurance and Compliance will review current Releases of Information for all active D&A clients once monthly for 60 days to ensure accurate documentation is being maintained. A summary of each review will be documented.
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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 document that a copy of each consent was offered to the client in one of one client records.
Client #3 was admitted on April 9, 2014 and is still an active client. Client #3 signed a consent to release information to a funding source on April 26, 2022. This consent to release information did not include documentation that the client was offered a copy of the consent.
These findings were reviewed with facility staff throughout the licensing process.
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Plan of Correction
The Release of Information form was edited to include a checkbox to document that the client was offered a copy of the consent, including staff initials.
Outpatient Program management will complete a training with all program staff on Releases of Information that includes documenting the client was offered a copy of the consent by November 1, 2022.
Quarterly chart reviews of D&A clients will be completed by Outpatient program management to ensure Releases of Information are being documented appropriately.
The Director of Quality Assurance and Compliance will review current Releases of Information for all active D&A clients once monthly for 60 days to ensure accurate documentation is being maintained. A summary of each review will be documented.
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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 to the project which included a familiarization with the fee schedule in two of five client records.
The plan of correction from the annual inspection conducted in January 2022, stated that all current and future clients will be provided with client orientation documentation, including fee schedules, by April 1, 2022.
Client # 1 was admitted on May 6, 2019 and is still an active client. There was no documentation that client #1 was provided with a fee schedule.
Client # 4 was admitted on August 12, 2020 and is still an active client. There was no documentation that client #4 was provided with a fee schedule.
These findings were reviewed with facility staff throughout the licensing process.
This is a repeat citation from the January 31, 2022 annual licensing inspection.
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Plan of Correction
Client files missing documentation that the client was provided with a fee schedule will be updated to include a signed copy of the fee schedule.
An intake checklist of all regulatory orientation information will be created for staff to use during the intake process with clients. All new D&A clients will sign the new checklist indicating that they received all orientation information, including a copy of the fee schedule.
Quarterly chart reviews of D&A clients will be completed by Outpatient program management to ensure orientation information is being documented appropriately.
The Director of Quality Assurance and Compliance will review orientation for all active clients once monthly for 60 days to ensure accurate documentation is being maintained. A summary of each review will be documented.
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