INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2024 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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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 complete an informed and voluntary consent to release information form prior to the disclosure of information in three of seven client records reviewed.
Client # 2 was admitted on September 7, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on September 7, 2023 and the form expired on March 7, 2024. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after March 7, 2024.
Client # 4 was admitted on November 30, 2023 and was discharged on May 10, 2024. There was evidence of a disclosure to the client's sibling around May 10, 2024; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 5 was admitted on September 5, 2023 and was discharged on February 27, 2024. There was evidence 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.
This is a repeat citation from the August 5, 2021, July 7, 2022, and June 29, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Milestone Rehabilitation procedure to obtain a written informed and voluntary consent from clients for the disclosure of information contained in clients records was reviewed in the staffing meeting on 06/17/2024. The project director conducted the additional training with the staff on requirements to update the written and voluntary consent forms every 6 month included clients discharged from the service.
The clinical supervisor is in contact with clients ## 2,4 and 5 in attempts to gather written consent forms to include in clients records for disclosures after discharges. All communications will be documented
The completion date is 08/31/2024.
The Project Director and the Clinical supervisor will review clinical records weekly to assure that the staff is obtaining written voluntary consent forms every 6 month for the disclosure of the information in clients records including disclosures of records of discharged individuals. . |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an incident involving a client's death or serious injury due to trauma, suicide, medication error or unusual circumstances.
The facility was notified of an off-site death of an active client around May 10, 2024; however, the incident was not reported to the Department at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 06/17/2024 the Project Director reviewed the Milestone Rehabilitation policy to file a written unusual incident report with the Department within 3 business days following the death, serious injury due to trauma, suicide, medication errors and unusual circumstances with the staff and retrained the staff on situations and instances of unusual incidents and reinforced the compliance with the policy, specifically as it relates to unusual incidents involving active and discharged individuals that reported by other parties and that happened in other than the Milestone facility locations.
The clinical supervisor has created a log of communications on unusual incidents received by other parties.
The Clinical supervisor and the Project Director will be responsible for the completion of unusual incident reports by therapists with the department within 3 business days. |
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 the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of seven client records reviewed.
Client # 1 was admitted on February 9, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 9, 2024; however, the plan did not include the frequency of treatment and rehabilitation services.
Client # 4 was admitted on November 30, 2023 and was discharged on May 10, 2024. The individual treatment and rehabilitation plan was completed on November 30, 2023; however, the plan did not include the frequency of treatment and rehabilitation services.
Client # 5 was admitted on September 5, 2023 and was discharged on February 27, 2024. The individual treatment and rehabilitation plan was completed on September 5, 2023; however, the plan did not include the frequency of treatment and rehabilitation services.
Client # 6 was admitted on February 20, 2024 and was discharged on April 19, 2024. The individual treatment and rehabilitation plan was completed on February 20, 2024; however, the plan did not include the frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project has the policy to include types and frequencies of treatments and rehabilitation services in individual treatment plans.
On 06/20/2024 the Clinical Supervisor conducted the additional training with the clinical staff on the requirement to include the frequency of treatment and rehabilitation services in individual treatment plans.
The Facility Director is also exploring the option to include the requirement as a "mandatory" field in the electronic version of the treatment plan in electronic health records.
The Clinical Supervisor will be responsible to review treatment plans monthly and make sure that the frequency of treatment and rehabilitation services are included in 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 review and update treatment and rehabilitation plans at least every sixty days in four of six applicable client records reviewed.
Client # 1 was admitted on February 9, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 9, 2024 and an update was due no later than April 9, 2024; however, the update was not completed until April 18, 2024.
Client # 2 was admitted on September 7, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 7, 2023 and an update was due no later than November 7, 2023; however, the update was not completed until March 5, 2024.
Client # 3 was admitted on January 11, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 11, 2024 and an update was due no later than March 11, 2024; however, the update was not completed until May 22, 2024.
Client # 5 was admitted on September 5, 2023 and was discharged on February 27, 2024. The individual treatment and rehabilitation plan was completed on September 5, 2023 and an update was due no later than November 5, 2023; however, the update was not completed until February 20, 2024.
This is a repeat citation from the July 7, 2022 and June 29, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Milestone Rehabilitation project has the policy to review and update treatment and rehabilitation plans every 60 days.
The EHR that has been developed by the project, doesn't have a capacity to update the treatment plan without the client being present. The client physical signature is required by the EHR design resulting some treatment plans been updated late.
The Project Director is in contact with the EHR developer to adjust settings and allow the treatment plan to be updated without the client present.
The estimated time to complete the revision is 08/31/2024.
As updates to the EHR software are complete, the staff will be trained to use the new version of the treatment plan when the client signature is not required.
Until the electronic version of the treatment plan is revised, all treatment plans that are due 60 days review and updates and if clients are not present, are to be completed by the staff manually in the printed on paper version and filed in clients records.
The Project Director will be responsible to monitor the 60 days review and updates of treatment plans annually until the EHR is updated and the staff is fully trained. |
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, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to obtain an informed and voluntary consent to release information form prior to the disclosure of client information were submitted and approved by the Department for the August 5, 2021, July 7, 2022, and June 29, 2023 annual licensing inspections. Failing to obtain an informed and voluntary consent to release information form prior to the disclosure of client information was again found to be a deficiency in the June 11, 2024 licensing inspection.
Plans of correction for failing to review and update treatment and rehabilitation plans at least every sixty days were submitted and approved by the Department for the July 7, 2022 and June 29, 2023 annual licensing inspections. Failing to review and update treatment and rehabilitation plans at least every sixty days was again found to be a deficiency in the June 11, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will be responsible to monitor the implementation of the Plan of Correction
The project Director and the Clinical supervisor will review all active and discharged clients clinical files to make sure the compliance with regulations 709.28 and 709.92.
The deadline to complete the review is 07/31/2024.
The Project Director will be responsible to monitor the completion of all steps to address all deficiencies outlined in the Department annual survey to make sure there will be no repeat citations. |