INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5, 2021 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that all counseling sessions cannot be seen or heard outside the counseling room. Counseling sessions occurring in the counselor's office adjacent to the medical director's office were able to be heard while in the medical director's office and in the hallway.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has purchased Noise Sound Machines for each therapy and procedure room to insure the privacy of counseling services.
It shall be a responsibility of the Facility Director and the Administrative Assistant to insure that the sound machine operate during business hours and the the program in compliance with the regulation 705.23. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on the physical plant inspection conducted on August 5, 2021, the facility failed to ensure that each bathroom had operable ventilation by exhaust fan or window. The exhaust fan in the located in the community bathroom was not operable at the time of inspection.
This is a repeat citation from the March 2, 2021 annual renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The exhaust fan in the bathroom was repaired on 08/09/2021 and is fully operational. The Facility Director shall be responsible to weekly check to insure exhausts fans and all appliances on the premises work properly.
Any malfunctioning will be documented as found and the maintenance services call will be placed immediately.
The facility is in full compliance of regulation 705.24 as of 08/09/2021 |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection conducted on August 5, 2021, the facility failed to ensure that each bathroom is maintained in a functional, clean and sanitary manner at all times. The bathroom located in the right side of the facility had ceiling tile with heavy water damage.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The ceiling tile with the water damage in the bathroom has been replaced. There was no other water damage found in the ceiling.
The Facility Director shall be responsible to weekly check all ceiling for any leakage or damage. Any spots found as damaged will be documented and the maintenance service call will be placed immediately.
The facility is in full compliance of regulation 705.24 as of 08/09/2021 |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on the physical plant inspection conducted on August 5, 2021, the facility failed to ensure that stairways, hallways and exits from room and from the nonresidential facility are unobstructed. The back emergency exit door located in the right side of the facility appeared to be broken and required additional force to open.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The back emergency exit door was repaired and now operates smoothly.
The Facility Director shall be responsible to insure all facility doors are in good operational conditions.
The Facility Director will document any malfunctioning weekly. The service call for repair will be made immediately.
The facility doors are now in compliance of 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 includes but is not limited to the disclosure of the officers, directors, and principal shareholders, was completed and made available to the public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director is working with the website developer to create the link in the company website so annual reports can be published for the public access and review.
Reports will include Annual financial, Governing Board and Shareholders Compositions.
It will be a responsibility of the Facility Director to publish annual reports as completed but no later than 07/01 in the year following the reporting year.
The project will be in compliance of regulation 709.22 on 09/15/2021.
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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 obtain a written, informed and voluntary consent to release information form from the client for the disclosure of information contained in six of seven client records reviewed.
Client # 1 was admitted on June 22, 2021 and was still 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 any of the disclosures.
Client # 2 was admitted on May 21, 2021 and was still 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 any of the disclosures.
Client # 4 was admitted on April 13, 2021 and was discharged on May 4, 2021. 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 any of the disclosures.
Client # 5 was admitted on March 15, 2021 and was discharged on May 14, 2021. 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 any of the disclosures.
Client # 6 was admitted on March 22, 2021 and was discharged on April 5, 2021. 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 any of the disclosures.
Client # 7 was admitted on April 30, 2021 and was discharged on July 2, 2021. 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 any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client orientation package has been revised. The authorization to release of information form has been revised. The consent to release information form will be signed by the client prior to any of disclosures.
The program clinical staff has been trained to use revised forms and to obtain a written, informed and voluntary consent for the disclosure of information contained in clients records.
The Facility Director and Clinical Supervisor will be reviewing clinical records monthly to insure that the revised consent form is used by the clinical staff and signed by the client.
The compliance with the regulation 709.28 will be monitored monthly. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to include documentation verifying the written acknowledgement by clients that they had been informed of their right to submit rebuttal data or memoranda to their own records in all seven client records reviewed.
This is a repeat citation from the March 2, 2021 annual renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clients Right form has been revised to reflect the verbiage that the client has the right to submit the rebuttal or memoranda to his/her records.
The Facility Director and Clinical Supervisor will be responsible to insure that the staff is trained and utilize the revised form.
The Clinical Supervisor will be reviewing clients records on the weekly basis to make sure the program is in compliance with the regulation 709.30 |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the project failed to include and implement a written medication policy and procedure that addresses the inspection of storage areas that ensures compliance with State and Federal laws and program policy, more specifically that disinfectants and drugs for external use are stored separately from oral and injectable drugs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medication Control Policy and Procedures have been created.
Inspections of storage areas will be conducted monthly. Inspections results and the documentation will be stored in electronic records keeping system.
The Registered Nurse and the Clinical supervisor shall be responsible to conduct monthly inspections and its record keeping.
The Policy and Procedure and the inspections schedule is in effect as of 08/16/2021 and in compliance with regulation 709.32. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop and implement, within their unusual incident reporting policies and procedures, how the facility would address the implementation of a timely and appropriate corrective action plan, when indicated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual Incident Policy has been updated to include the timing and implementation of corrective action plan.
The Facility Director shall be responsible for the training and implementation of revised policy.
The program Unusual Incident policy is in compliance with the regulation 709.34 as of 08/30/2021 |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop and implement, within their unusual incident reporting policies and procedures, how the facility would address the ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual Incident Policy has been updated to include the ongoing monitoring of the corrective action plan.
The Facility Director shall be responsible for the training and implementation of revised policy.
The program Unusual Incident policy is in compliance with the regulation 709.34 as of 08/30/2021 |
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 properly document the type and frequency of treatment and rehabilitation services in the client's comprehensive treatment plan in four of seven client records reviewed.
Client # 1 was admitted on June 22, 2021 and was still active at the time of inspection. The comprehensive treatment plan was completed on June 22, 2021; however, the plan did not include what type of services were to be provided and the frequency of those services.
Client # 2 was admitted on May 21, 2021 and was still active at the time of inspection. The comprehensive treatment plan was completed on May 21, 2021; however, the plan did not include what type of services were to be provided and the frequency of those services.
Client # 3 was admitted on April 16, 2021 and was still active at time of inspection. The comprehensive treatment plan was completed on April 16, 2021; however, the plan did not include what type of services were to be provided and the frequency of those services.
Client # 4 was admitted on April 13, 2021 and discharged on May 4, 2021. The comprehensive treatment plan was completed on April 16, 2021; however, the plan did not include what type of services were to be provided and the frequency of those services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 08/09/2021 the Facility Director has conducted the training with all clinical staff on the client's Comprehensive treatment plans to make sure clinicians and counselors reflect the frequency of treatment and rehabilitation services in treatment plans.
The Clinical Supervisor shall be responsible to review treatment plans to insure clinical records are in compliance with the regulation 709.92. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to properly document the proposed type of support services in the client's individual treatment plan in four of seven client records reviewed.
Client # 1 was admitted on June 22, 2021 and was still active at the time of inspection. The comprehensive treatment plan was completed on June 22, 2021; however, the plan did not document any proposed type of support services.
Client # 2 was admitted on May 21, 2021 and was still active at the time of inspection. The comprehensive treatment plan was completed on May 21, 2021; however, the plan did not document any proposed type of support services.
Client # 3 was admitted on April 16, 2021 and was still active at time of inspection. The comprehensive treatment plan was completed on April 16, 2021; however, the plan did not document any proposed type of support services.
Client # 4 was admitted on April 13, 2021 and discharged on May 4, 2021. The comprehensive treatment plan was completed on April 16, 2021; however, the plan did not document any proposed type of support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 08/09/2021 the Facility Director has conducted the training with all clinical staff on the client's Comprehensive treatment plans to make sure clinicians and counselors reflect the proposed type of support services in treatment plans.
The Clinical Supervisor shall be responsible to review treatment plans to insure clinical records are in compliance with the regulation 709.92. |