INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 7, 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 Rehabilitation, LLC 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 the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that all staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics in five of five applicable personnel records reviewed.
Employee #3 was hired as a clinical supervisor on March 10, 2021 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than March 10, 2022; however, there was documentation of one hour of HIV/AIDS and one hour of TB/STD training at the time of inspection.
Employee #4 was hired as a counselor on March 10, 2021 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than March 10, 2022; however, there was documentation of one hour of HIV/AIDS and one hour of TB/STD training at the time of inspection.
Employee #5 was hired as a counselor on March 10, 2021 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than March 10, 2022; however, there was documentation of one hour of HIV/AIDS and one hour of TB/STD training at the time of inspection.
Employee #6 was hired as a counselor on March 10, 2021 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than March 10, 2022; however, there was documentation of one hour of HIV/AIDS and one hour of TB/STD training at the time of inspection.
Employee #7 was hired as a counselor on March 10, 2021 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than March 10, 2022; however, there was documentation of one hour of HIV/AIDS and one hour of TB/STD training at the time of inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employees #3,4,5,6 and 7 have completed required 6 hours of HIV/AIDSand 4 hours of tuberculosis and sexually transmitted diseases trainings as of 07/26/2022.
The Clinical Supervisor shall be responsible to review and monitor personnel HIV/AIDS, sexually transmitted diseases and other health related training monthly in accordance with regulations 704.11. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's August 2021 through June 2022 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
The facility's hours of operation are Monday through Friday 8:00AM - 8:00PM and Saturday 8:00AM - 5:00PM. All the fire drills conducted during the reviewed period were completed during the hours of 12:15PM through 2:30PM. There were no fire drills conducted during the morning or evening hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and his designee will be conducting fire drills on different working days of the week, at different times of the day including day and evening hours.
The Facility Director will be responsible to schedule fire drills on different days and times and will monitor the fire drill logs monthly to assure the compliance with the regulation 705.28 |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on an administrative review, the facility, which accepts public funding, failed to ensure that an annual report, which is to include but is not limited to the disclosure of the officers, directors, and principal shareholders, was completed and made available to the public.
This is a repeat citation from the August 5, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director is in the agreement with the local newspaper to publish the annual financial statement, the Board of Director Composition and a list of directors and executives.
The annual financial statement, the Board of Director and the list of directors and executives will be published no later than 09/30/2022.
The Facility Director and Financial Director shallowing publish the annual financial report, the Board Composition and the list of Directors and executives no later than July 1 of the year following the reporting year. |
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 obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in four of seven client records reviewed.
Client #1 was admitted on December 29, 2021 and was active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #3 was admitted on October 26, 2021 and was active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #4 was admitted on November 2, 2021 and was discharged on March 16, 2022. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #6 was admitted on February 9, 2022 and was discharged on April 6, 2022. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This is a repeat citation from the August 5, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The written informed and voluntary consent form is a part of the client orientation package. In the staff meeting on 07/15/2022 the regulation 709.28 was reviewed again with the staff and the requirement to obtain a written informed and voluntary consent form for the information contained in clinical records was addressed.
Clinicians will follow up with clients #1,3,4,6 to make sure they sign the written informed and voluntary consent forms.
The Facility Director and Clinical Supervisor shall review all new intakes and orientation packages monthly to make sure that the written and voluntary consent form is signed and included in the clients records. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in one of seven client records reviewed. Additionally, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in three of seven client records reviewed.
Client #2 was admitted on November 19, 2021 and was active at time of inspection. A release of information form to the funding source was signed and dated by the client on November 19, 2021, allowed for the release of "all medical record" , which exceeded the limits established by 4 Pa. Code 255.5.
Client #5 was admitted on January 25, 2021 and was discharged on April 8, 2022. A release of information form to the funding source was signed and dated by the client on January 25, 2022, allowed for the release of "all medical record" , which exceeded the limits established by 4 Pa. Code 255.5.
Client #7 was admitted on October 22, 2021 and was discharged on April 6, 2022. A release of information form to the funding source was signed and dated by the client on October 22, 2021, allowed for the release of "all medical record" , which exceeded the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to another treatment provider was signed and dated by the client on October 22, 2021; however, the specific information to be disclosed was not documented on the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The informed and voluntary consent form for the disclosure of information contained in client records was revised to accommodate the specific information to be released. The information to be released will be limited to 5 parameters defined in 4 Pa Code 255.5.
in the training on 07/15/2022 the clinical staff was trained to document the specific information to be released on the informed and voluntary consent form and was re-trained on 5 parameters of the 4 Pa Code 255.5.
The Facility Director and Clinical Supervisor shall review new intakes and orientation packages monthly to make sure the revised informed and voluntary consent form is used by the staff and the staff documents the specific info to be disclosed in accordance with the regulation 709.28 |
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 a client consent was offered to the client in four of seven client records reviewed.
Client #2 was admitted on November 19, 2021 and was active at the time of inspection. Release of information forms to a funding source and a physician were signed and dated by the client on November 19, 2021; however, there was no documentation that a copy of either form was offered to the client.
Client #3 was admitted on October 26, 2021 and was active at the time of inspection. Release of information forms to another treatment provider and a physician were signed and dated by the client on October 26, 2021; however, there was no documentation that a copy of either form was offered to the client.
Client #4 was admitted on November 2, 2021 and was discharged on March 16, 2022. A release of information form to a medical group was signed and dated by the client on November 2, 2021; however, there was no documentation that a copy of the form was offered to the client.
Client #7 was admitted on October 22, 2021 and was discharged on April 6, 2022. Release of information forms to a funding source and two treatment providers were signed and dated by the client on October 22, 2021; however, there was no documentation that a copy of any of the forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A copy of signed informed and voluntary consent form will be kept in clients records starting immediately. The form is updated to have the section documenting that the client was offered a copy of the consent form and the section with the client signature of the receipt of the consent form. The form will also have a verbiage documenting clients' refusal to receive the consent form. This requirement will be addressed with clinicians in the upcoming training on 08/10/2022
The clinical supervisor will follow up with clinicians to collect informed and voluntary consent forms signed by clients #2,3,4 and 7 and will have completed forms filed in their clinical records.
The clinical supervisor will be reviewing all intakes and orientation packages monthly to make sure the project is in compliance with the regulation 709.28. |
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
Based on a review of client records, the facility failed to document, in the client's individual treatment and rehabilitation plan, the type and frequency of treatment and rehabilitation services in five of seven client records reviewed.
Client #1 was admitted on December 29, 2021 and was active at the time of inspection. The comprehensive treatment plan was completed on December 29, 2021; however, the plan did not include the frequency of treatment and rehabilitation services.
Client #3 was admitted on October 26, 2021 and was active at time of inspection. The comprehensive treatment plan was completed on October 26, 2021; however, the plan did not include the frequency of treatment and rehabilitation services.
Client #4 was admitted on November 2, 2021 and was discharged on March 16, 2022. The comprehensive treatment plan was completed on November 2, 2021; however, the plan did not include the frequency of treatment and rehabilitation services.
Client #6 was admitted on February 9, 2022 and was discharged on April 6, 2022. The comprehensive treatment plan was completed on February 9, 2022; however, the plan did not include the frequency of treatment and rehabilitation services.
Client #7 was admitted on October 22, 2021 and was discharged on April 6, 2022. The comprehensive treatment plan was completed on October 22, 2021; however, the plan did not include the frequency of treatment and rehabilitation services.
This is a repeat citation from the August 5, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 07/20/2022 the clinical supervisor conducted a training to the clinical staff on the requirement to include the frequency of treatment sessions in individual treatment plans.
The clinical supervisor will be responsible to monthly review and make sure the frequency of treatment sessions is included in Individual treatment plans in accordance with the regulation 709.92. |
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 ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in six of six applicable client records reviewed.
Client #1 was admitted on December 29, 2021 and was active at the time of inspection. The comprehensive treatment plan was completed on December 29, 2021, and the next update was due no later than March 1, 2022; however, the plan was completed on March 2, 2022.
Client #2 was admitted on November 19, 2021 and was active at the time of inspection. A treatment plan update was completed on January 20, 2022, and the next update was due no later than March 20, 2022; however, the plan was completed on April 8, 2022.
Client #3 was admitted on October 26, 2021 and was active at the time of inspection. The comprehensive treatment plan was completed on October 26, 2021, and the next update was due no later than December 26, 2021; however, the plan was completed on December 30, 2021.
Client #4 was admitted on November 2, 2021 and was discharged on March 16, 2022. A treatment plan update was completed on January 4, 2022, and the next update was due no later than March 4, 2022; however, the plan was not completed prior to discharge.
Client #5 was admitted on January 25, 2022 and was discharged on April 8, 2022. The comprehensive treatment plan was completed on January 25, 2022, and the next update was due no later than March 25, 2022; however, the plan was not completed prior to discharge.
Client #7 was admitted on October 22, 2021 and was discharged on April 6, 2022. The comprehensive treatment plan was completed on October 22, 2021, and the next update was due no later than December 22, 2021; however, the plan was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 07/20/2022 the Facility Director conducted the training to all clinical staff on treatment and rehabilitation plans. All clinical staff shall review and update treatment and rehabilitation plans every 60 days.
The Facility Director shall monitor the compliance with the regulation 709.92 by reviewing treatment and rehabilitation plans every months to make sure review and updates happen every 60 days. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services were being provided according to the individual treatment and rehabilitation plan in two of two applicable client records reviewed.
Client #2 was admitted on November 19, 2021 and was active at the time of inspection. The comprehensive treatment plan dated November 19, 2021 and the treatment plan update dated January 20, 2022, documented weekly individual counseling sessions. There was no documentation, in the record, of individual counseling sessions occurring during the weeks of December 5, 2021 - December 25, 2021, January 2, 2022 - January 8, 2022, February 27, 2022 - March 12, 2022, and March 20, 2022 - April 2, 2022.
Client #5 was admitted on January 25, 2022 and was discharged on April 8, 2022. The comprehensive treatment plan dated January 25, 2022 documented weekly individual counseling sessions. There was no documentation, in the record, of individual counseling sessions occurring during the weeks of February 13, 2022 - April 2, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The requirement to follow and provide counseling services as defined in individual treatment and rehabilitation plans was addressed with the clinical staff. In situations of "no shows" or "no answers" from clients all attempts by clinicians and the administrative staff to reach out and remind about upcoming sessions should be clearly documented in clinical records and reported to the clinical supervisor or the medical director.
The clinical supervisor will be reviewing clinical records to assure that therapy and counseling sessions happen and documented as prescribed in individual treatment and rehabilitation plans. The clinical supervisor will be responsible to assure the staff documents all missed appointments in clinical records. |