INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 3-4, 2020 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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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
The facility failed to document a written policy to address the relapse of recovering clinical personnel and the discipline of nonrecovering employees who abuse alcohol and other drugs.
The policy and procedure manual was reviewed on February 3-4, 2020. There was no documentation of a policy for the above mentioned.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed a policy entitled "Drug-Free Workplace". This policy addresses use in the workplace, reasonable suspicion, reasonable suspicion testing, consequences and return to work for all employees. Policy has been provided to all employees and is available to review on our Intranet site. |
704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The facility failed to document a policy to address the recruitment and hiring of staff persons who are appropriate to the population to be served.
The policy and procedure manual was reviewed on February 3-4, 2020. There was no documentation of policies for the above mentioned.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed a policy entitled "Recruitment and Hiring." This policy addresses All recruitment and hiring practices. It specifically address hiring of persons appropriate to the population served. Policy has been provided to all employees and is available to review on our Intranet site. |
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
The facility failed to ensure staff persons received the required 6 hours of HIV/AIDS and 4 hours of STD/TB training in five of five personnel records.
Seven personnel records were reviewed on January 3-4, 2020. Five personnel records required the completion of the required training. Employee records # 3, 4, 5, 6 and 7 did not
document the completion of the training.
Employee # 3 was hired as a counselor on April 1, 2018. The 6 hours of HIV/AIDS and 4 hours of STD/TB training was to be completed by April 1, 2019. There was no documentation the training had been completed.
Employee # 4 was hired as a counselor on April 1, 2018. The 6 hours of HIV/AIDS and 4 hours of STD/TB training was to be completed by April 1, 2019. There was no documentation the training had been completed.
Employee # 5 was hired for the front desk on April 27, 2017. The 6 hours of HIV/AIDS and 4 hours of STD/TB training was to be completed by April 27, 2019. There was no documentation the training had been completed.
Employee # 6 was hired for the front desk on April 27, 2017. The 6 hours of HIV/AIDS and 4 hours of STD/TB training was to be completed by April 27, 2019. There was no documentation the training had been completed.
Employee # 7 was hired for the front desk on April 27, 2017. The 6 hours of HIV/AIDS and 4 hours of STD/TB training was to be completed by April 27, 2019. There was no documentation the training had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Milestone will utilize the DDAP training curriculum to train all staff in HIV/AIDS and STD/TB training. We have a master's level RN who will provide training to all existing employees. Milestone has adequate training space and support to accomplish this by June 1. Milestone will utilize our existing training department to track completion of the trainings via acknowledgement forms and database. All staff will receive new/ongoing training on our training policy, which lists timelines of required training. Assistant Executive Director will be responsible for ensuring that POC is completed. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to ensure that counselors completed at least 25 clock hours or training annually in two of two records.
Seven personnel records were reviewed on February 3-4, 2020. Two were reviewed as counselors and required 25 clock hours of annual training for the 2019 training year. Employees # 3 and 4 did not document 25 hours of training.
Employee # 3 had 10.5 hours of training documented for 2019.
Employee # 4 had 0 hours of training documented for 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisor have been made aware of the annual requirement. It was previously misunderstood. Existing staff have a training plan which will require them to receive 25 hours of training by the end of this calendar year. Staff have already begun. |
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
The facility failed to document written procedures for the evacuation and transfer of clients and staff to a safe location.
The policy and procedure manual was reviewed on February 3-4, 2020. There was no documentation of procedures for the above mentioned.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Milestone is in the process of developing a policy for the evacuation and transfer of clients and staff to a safe location. Currently, we have evacuation protocols for each facility, but no official policy. Policy will be finalized by 3/31/20. |
705.27 (4) (ii) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
The facility failed to document written procedures for the assignments of staff during emergencies.
The policy and procedure manual was reviewed on February 3-4, 2020. There was no documentation of procedures for the above mentioned.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Milestone is in the process of developing a policy for the evacuation and transfer of clients and staff to a safe location. This policy will also include assignment of staff during the emergency. Currently, we have evacuation protocols for each facility, but no official policy. Policy will be finalized by 3/31/20. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
The facility failed to maintain a portable fire extinguisher on each floor.
The physical plant inspection was conducted on February 4, 2020. The facility did not have any fire extinguishers on the floor. The facility has a integrated fire system.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone is in the process of requesting an exception to 705.28. Our Penn Center facility has an integrated fire system with sprinklers. Initial inspection indicated that our facility met the requirement. If an exception is not granted, Milestone will purchase the minimum number of fire extinguishers and maintain them. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document a written fire drill log that included 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.
The fire drill logs were reviewed for the period of February 2019 to Janaury 2020. The fire drill logs did not document the required information.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2018 and 2019 licensing inspections.
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Plan of Correction
A new fire drill log has been created that includes 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. This new form is now in use. |
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
The facility failed to document the project director annually updated and signed the policy and procedure manual.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual had not been signed by the project director for 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A review form has been created that indicates that the project director has reviewed the policy and procedure manual. A policy has been developed that requires annual review and a signature. |
709.24 (a) LICENSURE Treatment/rehabilitation Management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
The facility failed to document the governing body adopted a written plan for the coordination of client treatment which included the definition of the target population, identification of treatment models and practices utilized by the facility, written procedures for the management if treatment services and written procedures for referral outlining cooperation with other providers.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document a written plan which included the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
An "Organizational Description of SUD Outpatient Services" had been previously developed and was approved by the Board of Directors. The description includes the definition of the target population, identification of treatment models and practices utilized by the facility, written procedures for the management if treatment services and written procedures for referral outlining cooperation with other providers. This document is available for review. |
709.26 (a) LICENSURE Personnel Management
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
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Observations
The facility failed to document the governing body adopted and implemented written policies and procedures in compliance with State and Federal employment laws which included the utilization of volunteers, supervision of staff and orientation of new employees.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document a written policy and procedure which included the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed the following policies: "Staffing", "Individual Supervision", and "Orientation". These policies state that Milestone does not employ volunteers and provides statements regarding compliance with state and federal employment laws. They also provide details regarding regulatory issues of supervision and orientation. These policies have been previously shared with all staff and are available to view on our agency intranet. |
709.28 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
The facility failed to document written procedures developed by the project director which complies with 4 Pa. Code 255.5 which included the procedure for the confidentiality of client identity and records and the identification of project staff having access to records and the methods by which staff gain access.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document a written procedure which included the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed a policy entitled "Confidentiality of Consumer/Client Records". This policy addresses general confidentiality concerns, but does not address Substance Use Disorders directly. Milestone is in the process of creating a policy to directly address the confidentiality of client records in our Substance Use Disorder program. The policy will be complete by 3/31/20. |
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 an informed and voluntary consent in six of six client records.
Six client records were reviewed on February 3-4, 2020. All six were reviewed for consents.
Clients # 1, 2, 3, 4, 5 and 6 were missing a consent for the funding agency.
The facility utilized a consent to release information form that 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, 2, 3, 4, 5 and 6.
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).
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 3-4, 2019 inspection.
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Plan of Correction
Milestone had previously developed a compliant authorization form that was not in use. The form is now in use. All staff have been provided the new form along with completion instruction. The new form does not require written notification to revoke. It also does not require a parent signature. This form is available for review. |
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
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in six of six client records reviewed.
Client records were reviewed on February 3-4, 2020. All were reviewed for client rights notification. There was no documentation that the clients # 1, 2, 3, 4, 5,and 6 were 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.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 4, 2019 inspection.
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Plan of Correction
A new client rights form has been developed which contains all 6 required rights listed in 709.30. This rights form will be provided to all clients for signature. All clients will also be given a copy. This client rights form has been added to the Milestone Client Rights policy, which indicates these procedures. The policy has been provided to all staff and is available on the agency intranet. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
The facility failed to document and implement a written policy and procedure regarding the use of medications by the client.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document a written policy and procedure which included the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone is in the process of developing a medication policy. Current protocols regarding medication storage and the administration of intra-muscular medication by RNs meet required guidelines, but have not been documented in policy format. The policy will be finalized by April 30, 2020. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to develop policies and procedures to respond to physical or sexual assault of staff or client.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone is in the process of developed an SUD specific Unusual Incident Reporting policy. The previous Incident Reporting policy did not specifically address physical or sexual assault. The new policy will specify all points related to 709.34. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
The facility failed to develop policies and procedures to respond to selling or use of illicit drugs on the premises.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed a "Drug-Free Workplace" policy. This policy addresses both the use and selling of illicit drugs on the premises. This policy has been shared with all staff and is available for review on the agency intranet. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
The facility failed to develop policies and procedures to respond to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
The facility failed to develop policies and procedures to respond to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone is in the process of developing a emergency response plan and a business continuity plan. This plan will address disaster response and protocols for agency closure. Plan will be complete by June 1 2020. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
The facility failed to develop policies and procedures to respond to theft, burglary, break-in or similar incident at the facility
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to develop policies and procedures to respond to an event at the facility requiring the presence of police, fire or ambulance personnel.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
The facility failed to develop policies and procedures to respond to a fire or structural damage to the facility.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
The facility failed to develop policies and procedures to respond to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
The facility failed to develop policies and procedures for the documentation of the unusual incident.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
The facility failed to develop policies and procedures for the reporting mechanism to ensure the reporting complies with State and Federal laws.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
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 and frequency of treatment and rehabilitation services in four of six client records.
Six client records were reviewed on February 3-4, 2020. All six were reviewed for treatment plans.
Client # 2 was admitted November 14, 2019. The individual treatment plan was documented November 15, 2019.
Client # 3 was admitted April 19, 2019. The individual treatment plan was documented May 5, 2019.
Client # 4 was admitted May 14, 2019. The individual treatment plan was documented August 23, 2019.
Client # 6 was admitted March 19, 2019. The individual treatment plan was documented April 30, 2019.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation form the January 4, 2019 inspection.
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Plan of Correction
Staff retraining on treatment plan requirements has been conducted. Retraining involved a review of the "Service Planning" policy, which is compliant with 709.92. Quality director and system administrator are working on resolve an electronic medical record issue that is not alerting staff of due dates. Treatment plans will be reviewed in weekly supervision and documented in supervision notes. |
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 an individual treatment plan update at least every 60 days in five of six client records.
Six client records were reviewed on February 3-4, 2020. All six were reviewed for treatment plans.
Client # 1 was missing updates due August 25 and October 25, 2019.
Client # 2 documented a late update. Update due to be completed by January 15, 2020 was completed on January 29, 2020.
Client # 3 was missing updates due September 23 and November 23, 2019.
Client # 4 was missing an update due October 23, 2019.
Client # 6 was missing updates due June 30 and August 30, 2019.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 4, 2019 inspection.
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Plan of Correction
Staff retraining on treatment plan requirements has been conducted. Retraining involved a review of the "Service Planning" policy, which is compliant with 709.92. Quality director and system administrator are working to resolve an electronic medical record issue that is not alerting staff of due dates. Treatment plans will be reviewed in weekly supervision and documented in supervision notes. |
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
The facility failed to document follow up information in three of three client records.
Six client records were reviewed on February 3-4, 2020. Three were reviewed as discharged records and required follow up. Per policy, the follow up is to be completed within one week of discharge.
Client # 4 was discharged on December 2, 2019. Follow up was not documented as of February 4, 2020.
Client # 5 was discharged on October 23, 2019. Follow up was not documented as of February 4, 2020.
Client # 6 was discharged on September 13, 2019. Follow up was not documented as of February 4, 2020.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff retraining on aftercare plan requirements has been conducted. Retraining involved a review of the "Aftercare Planning" policy, which is compliant with 709.93. Supervisor will review all discharges in individual weekly supervision to ensure that follow-up has occurred. |