INITIAL COMMENTS
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This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 02, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure.
Based on the findings of Part 2, an 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.
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection conducted on Tuesday, March 02, 2021, the facility failed to ensure that the building was safe and in good repair.
emergency exit door had a broken latch which made it difficult to exit
were observed outside by the exit doors in the back and side of the facility
located in the right side of the facility had ceiling tile with heavy water damage
air conditioning/heating vents obstructed with paper (office 24 and office 25)
The finding was discussed with facility
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Plan of Correction
The Emergency door latch has been repaired.
The ceiling with water damage has been replaced.
Air Conditioning and heating vents in rooms 24 and 25 have been cleaned up.
Facility Director is responsible to assure these repairs are completed and will monitor and check all doors and appliances weekly if for any damages and malfunctioning. Any malfunctioning will be noted weekly and the service calls for repairs will be made.
705.22 - Outpatient Facility. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection conducted on Tuesday, March 02, 2021, the facility had a portable space heater located in the medical doctor ' s office.
The findings were discussed with facility
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Plan of Correction
The portable space heater was removed from the premises immediately.
The Project Director is responsible to make sure the staff doesn't bring any electrical (heating) equipment going forward.
Outpatient Facility Licensing 705.26 |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant inspection conducted on Tuesday, March 02, 2021, the facility failed to ensure fire extinguishers were inspected annually. Last documented inspection done January 2020.
The finding was discussed with the facility.
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Plan of Correction
The extinguisher company conducted the inspection of all extinguishers and found them all to be operable. Tags were marked with the date of 03/18/2021
The facility director will be responsible to keep a log of due date of extinguishers inspections and to monitor the log and tags monthly to make sure inspections completion by due date. The Facility Director will document and date these checks in the check log monthly.
Outpatient Facilities: 705.28. |
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 Tuesday, March 02, 2021, the facility failed to ensure proper functioning of exhaust fan with community bathroom.
The findings were discussed with facility
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Plan of Correction
The exhaust fan in the bathroom was repaired and fully operational now
The Project Director is responsible to weekly check and make sure all appliances, exhausts and the ventilation system work properly. Any malfunctioning will be documented as found and the service call will be place immediately. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with the PA Department of Health Licensing Alert 01-11, Milestone Rehabilitation submitted the signed statement in 2020 to request the exception to this requirement as the annual gross income was below $500,000.
Milestone Rehabilitation received the approval letter from PA DDAP dated 05/26/2020 and signed by Bureau Director, stating that" this exception will remain valid until the project's drug and alcohol services gross income exceeds $500,000". The income in FY2020 didn't reach the benchmark required the CPA audit based on the exception granted by the DDAP office.
The DDAP letter was emailed to the review team and will be available to the department upon the request.
The Project Director will be responsible to the up keep of the letter and obtain the service of CPA for an annual audit if the gross income exceeds $500,000. The review of the annual gross income will be conducted in February of 2022 and the decision on the CPA audit will be made based on the FY2021 gross income amount.
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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 the review of client records on Tuesday, March 02, 2021, 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 four of ten records.
7 admitted on 11/04/20 - consent dated 11/04/20 to funding source
8 admitted on 11/11/20 - consent dated 11/11/20 to funding source
9 admitted on 10/29/20 - consent dated 10/29/20 to funding source
Client 10 admitted on 10/27/20 - consent dated - 11/02/20 to funding source
The findings were discussed with facility
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Plan of Correction
Authorization (consent) form to disclose the information to funders has been removed.
Project Director will be responsible to make sure this form is not used going forward. During the staff meeting following the review, the clinical and administrative staff was trained on the 4 Pa. Code 255.5 (b) to make sure they understand the policy and comply with the disclosure requirements as it apply to funders.
The project Director will be checking clinical files monthly to make sure the old form is not used by the staff and will document this review as a part of the overall monthly clinical records review process. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on the review of client record on Tuesday, March 02, 202, the facility failed to document when the witnessed signed or when the client signed the release form in 10 of 10 records. The form only had one spot for a date to cover both signatures.
The findings were discussed with facility
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Plan of Correction
The consent form was revised to add date spots for each signature.
The Project Director is responsible that the staff use the revised form and use date spots for each signature. The staff was also explained and trained to fill the date on each signature on the release form. The facility director will be reviewing completed forms in the weekly basis to make sure they are complete properly and in compliance with requirements. |
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 the review of client record on Tuesday, March 02, 2021, the facility failed to provide written acknowledgement that client were offered a copy of signed consent in 10 of 10 records.
The findings were discussed with facility
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Plan of Correction
The Consent form has been revised to reflect the acknowledgement that the client was offered a copy of signed consent.
The Project Director will be responsible that the revised form is used by the staff and the acknowledgement from the client is received.
The clinical staff was trained to obtain the written acknowledgement that clients were offered a copy of signed content.
Milestone clinical supervisor will review all existing clinical records to make sure clinicians obtain acknowledgements from clients and will monitor all upcoming intakes and consent forms to make sure the staff comply and obtain this acknowledgement. |
709.28 (e) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(e) When consent is not required, the project personnel shall:
(1) Fully document the disclosure in the client records.
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Observations
Based on the review of client record on Tuesday, March 02, 2021, the facility failed to provide written acknowledgement that all clients are able to verbally revoke consent in 10 of 10 records.
Client #1 admitted on 11/23/20
Client #2 admitted on 09/30/20
Client #3 admitted on 11/20/20
Client #4 admitted on 12/16/20
Client #5 admitted on 11/16/20
Client #6 admitted on 10/28/20
Client #7 admitted on 11/04/20
Client #8 admitted on 11/11/20
Client #9 admitted on 10/29/20
Client #10 admitted on 11/02/20
The finding was discussed with facility
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Plan of Correction
The Consent form has been revised to add the written acknowledgement that the client can verbally revoke the consent.
The Project Director will be responsible to make sure the staff will use the revise form.
The Milestone staff was trained to incorporate this new form going forward. The Milestone clinical supervisor will review and update all existing clinical records with this written acknowledgement as individuals come for the next appointment. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of client record on Tuesday, March 02, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
A client receiving care or treatment under section 7 of the act (71 P.S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
This finding was discussed with the facility.
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Plan of Correction
The client rights form has been revised to include the verbiage that the client shall retain civil rights and liberties except as provided by statute and that the client may not be deprived of a civil right solely by reason of treatment.
The Project Director will be responsible that the revised form is used by the staff going forward. The staff was trained to make sure they use the new form, and trained to explain clients that they can not be deprived of civil right solely by reason of treatment.
The clinical supervisor will will review existing completed forms to include the verbiage and to sign with clients and will be reviewing clinical files weekly to make sure the staff is using the revised form going forward. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on the review of client record on Tuesday, March 02, 2021, the facility failed to include written acknowledgement by clients that they have been notified of their client rights in ten of ten records.
The following verbiage failed to arrear within the client record:
The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
The findings were discussed with facility
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Plan of Correction
The client rights form was revised to include the written acknowledgement that the client has been notified of the Milestone Rehabilitation policy do not discriminate on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in the provision of services.
The project Director will be responsible that the staff utilize the revised form.
The staff was trained on the new form and how to obtain the written acknowledgement that they have been notified of their client rights. The Milestone clinical supervisor will update all existing clinical records with the new form and will make sure it is signed by clients.
The clinical supervisor will conduct weekly reviews tomake sure the staff is utilizing the revised forms. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of client record on Tuesday, March 02, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
This finding was discussed with the facility.
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Plan of Correction
The client rights form has been revised to include the verbiage that the client has a right to inspect his/her records and that the project Director, Medical Director or Clinical Supervisor may temporary remove portions of the records prior to the inspection of the client if the information may possible be detrimental to the client.
The Project Director will be responsible that the revised form is implemented and used by the staff going forward.
The staff was trained to utilize the revised form. The clinical supervisor will update current files with this new form and will make sure clients receive the revised form when they come for appointments.
The clinical supervisor will monitor the compliance weekly going forward. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on the review of client record on Tuesday, March 02, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
Clients have the right to appeal a decision limiting access to their records to the director.
This finding was discussed with the facility.
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Plan of Correction
The client rights form has been revised to include the verbiage that the client has the right to appeal a decision limiting the access to his/her records.
The facility Director has revised the client rights form to include the verbiage that Clients have the right to appeal a decision limiting access to their records to the director.
The clinical staff was trained to use the new revised form during the intake,
The clinical supervisor will review all existing clinical records to make sure the revised form is provided to clients when they come for the next appointment. The clinical supervisor will monitor all records weekly to assure the staff completes the correct clients right form. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on the review of client record on Tuesday, March 02, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
This finding was discussed with the facility.
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Plan of Correction
The client rights form has been revised to reflect the verbiage that the client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records
The Project Director is responsible to implement the revised client rights form and make sure the staff is using it going forward.
The staff was trained to utilize the revised client rights form.
The clinical supervisor has reviewed all existing clients files to make sure clients are provided the revised form when they come for the next appointment. The clinical supervisor will be monitoring the staff to use the correct client rights on the weekly basis. |
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 the review of client record on Tuesday, March 02, 2021, the facility failed to include the following verbiage on the client rights form that the client receives.
Clients have the right to submit rebuttal data or memoranda to their own records.
This finding was discussed with the facility.
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Plan of Correction
The client rights 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 Project Director is responsible to implement the revised client rights form and make sure the staff is using it going forward.
The staff was trained to utilize the revised client right form.
The clinical supervisor has reviewed all existing clients records to make sure the revised form is provided to clients when they come for the next appointment.
The clinical supervisor will be reviewing medical records on the weekly basis to make sure the staff is using the revised client rights form. |
709.91(b)(2)(i) 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:
(i) Project policies.
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Observations
Based on the review of client record on Tuesday, March 02, 2021, the facility failed to provide written acknowledgement that clients where provided with an orientation of services in six of ten records.
Client #1 admitted on 11/23/20
Client #2 admitted on 09/30/20
Client #3 admitted on 11/20/20
Client #4 admitted on 12/16/20
Client #5 admitted on 11/16/20
Client #6 admitted on 10/28/20
The findings were discussed with facility
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Plan of Correction
Intake forms will be revised to include the acknowledgement that clients have been provided with the service orientation.
The Project Director will be responsible to include the acknowledgement in intake forms that clients have been provided with an orientation of Milestone Rehabilitation services.
The staff was re-trained on the requirement to provide clients with an orientation of services and to use the revised form with the client acknowledgement that the client has received.
The clinical supervisor among with the appropriate clinical staff will be responsible to complete the orientation of services for clients ## 1,2,3,4,5 and 6 and obtained the revised forms with the acknowledgement that they received such orientation when they come for the appointment next time.
The clinical supervisor will review all new intake records weekly to make sure the clinical staff provides orientation of services and clients sign the acknowledgement of it. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records on Tuesday, March 02, 2021, the facility failed to provide a complete client record relating to drug and/or alcohol history in five of ten records.
Client #1 admitted on 11/23/20
Client #3 admitted on 11/20/20
Client #4 admitted on 12/16/20
Client #5 admitted on 11/16/20
Client #6 admitted on 10/28/20
The findings were discussed with facility
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Plan of Correction
Clients records will be reviewed to make sure the drug and alcohol history records are included in intake documentations.
The project Director will be responsible for the oversight and compliance with this procedure.
The clinical supervisor will work with clinicians to update the drug and alcohol history in clinical files of clients # 1,3,4,5 and 6.
The clinical supervisor will be responsible to review clinical records weekly to make sure the drug and alcohol history is included in all new clinical records.
Clinicians were re-trained on the requirement to include all drug and accohol history in clients records. The clinical supervisor will monitor records weekly to make sure the staff is in compliance with this regulation. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client record on Tuesday, March 02, 2021, the facility failed to provide a complete client record relating to personal history in three of ten records.
Client #4 admitted on 12/16/20
Client #5 admitted on 11/16/20
Client #6 admitted on 10/28/20
The findings were discussed with facility
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Plan of Correction
Clients records will be reviewed to make sure the personal history records are included in intake documentations.
The Project Director will be responsible for the oversight and compliance with this procedure.
The clinical supervisor will follow up with the appropriate staff to make sure the personal history is updated in clinical records of clients ## 4,5 and 6.
The recurrent training will be updated with reminders to include the personal history in clinical files,
The clinical supervisor will be reviewing clinical records weekly to monitor the compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client record on Tuesday, March 02, 2021, the facility failed to provide a complete client record relating to psychosocial evaluation in ten of ten records.
Client #1 admitted on 11/23/20
Client #2 admitted on 09/30/20
Client #3 admitted on 11/20/20
Client #4 admitted on 12/16/20
Client #5 admitted on 11/16/20
Client #6 admitted on 10/28/20
Client #7 admitted on 11/04/20
Client #8 admitted on 11/11/20
Client #9 admitted on 10/29/20
Client #10 admitted on 11/02/20
The findings were discussed with facility
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Plan of Correction
Clients whose charts were reviewed during the license visit on 03/02/2021 were transferred to Milestone Rehabilitation from the Psychiatric outpatient program (Bustleton Mental Health Institute). Their psychosocial evaluation were completed in psychiatric outpatient program previously. As the Medical Director reviewed the data and info from these evaluations, he decided the info was sufficient and made a decision not to complete repeated evaluations to admin them to the drug and alcohol program.
Psychosocial evaluations of these clients will be completed again to address findings from the licensing visit in next few months - timeframe is a subject to COVID-19 environment and ability of clients to come to the facility.
The intake process will include the psychosocial evaluation for all client looking to receive services at Milestone rehabilitation.
Project Director and Medical Director will be responsible for the completion psychosocial evaluations as clients come to the facility. The staff has been informed in the staff meeting happened right after the survey visit.
The Project Director will be checking all new intakes on the monthly basis to make sure Psychosocial evaluations are completed at the time of intakes. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client record on Tuesday, March 02, 2021, the facility failed to provide written documentation that a preliminary treatment was developed in three of ten records.
Client #1 admitted on 11/23/20
Client #4 admitted on 12/16/20
Client #6 admitted on 10/28/20
The findings were discussed with facility
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Plan of Correction
The intake documentation will be reviewed to make sure it includes a preliminary treatment plan. The staff will be re-trained on the intake documentations to make sure the preliminary treatment documentation is included in intake clients records.
The project Director and Medical Director will be responsible for the oversight and compliance of this procedure and documentation requirements.
The Medical Director will review clinical files of clients #1,4 and 6 to make sure the documentation reflects the development of the preliminary treatment plan. (completed on 04/09/21).
The Medical director will be reviewing all clinical files monthly to make sure that the documentation on the development of the preliminary treatment plan is a part of clients records. The Medical Director will sign the preliminary treatment plan upon review.
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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 the review of client record on Tuesday, March 02, 2021, the facility failed to provide written documentation that treatment plans were being updated timely in seven of ten records. Per facility's policy, updates are required every 60days after the comprehensive treatment plan
Client #2 admitted on 09/30/20 - 1st TP created on 09/30/20 update required on 11/30/20 never completed
Client #5 admitted on 11/16/20 - 1st TP created on 11/16/20 update required on 01/16/21 never completed
Client #8 admitted on 11/11/20 - 1st TP created on 11/11/20 update required on 01/11/21 never completed
Client #9 admitted on 10/29/20 - 1st TP created on 10/29/20 update required on 12/29/20 never completed
Client #10 admitted on 11/02/20 - 1st TP created on 11/02/20 update required on 01/02/21 never completed
The findings were discussed with facility
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Plan of Correction
60 days updates have not been completed on time due to the COVID-19 environment. All treatment plans will be updated without clients signatures as advised during the licensing visit.
Project Director will be responsible for having these updates completed by clinicians. The clinical supervisor will be reviewing clinical records weekly to make sure the staff completes TP updates timely.
The staff was trained and informed that TP updates can be updated without clients present but with other means of communications. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records on Tuesday, March 02, 2021, the facility failed to provide written documentation of case consultations being conducted in seven of ten records.
Client #2 admitted on 09/30/20
Client #3 admitted on 11/20/20
Client #5 admitted on 11/16/20
Client #7 admitted on 11/04/20
Client #8 admitted on 11/11/20
Client #9 admitted on 10/29/20
Client #10 admitted on 11/02/20
The findings were discussed with facility
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Plan of Correction
Case consultation notes are included in treatment plan updates. As treatment plan updates are completed, case consultation notes will be included. See the observation # 1883 above.
The Project Director will be responsible for completion of treatment plan updates including case consultation notes.
The clinical supervisor will monitor clinical files weekly to make sure TP updates and case consultation are documented timely.
The clinical supervisor will work with clinicians to make sure all missing TP and case consultations are updated and documented in clinical records. |