INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 18, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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:
|
Plan of Correction
|
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to maintain outpatient counselor caseloads at or below 35:1 in two of four counselor caseloads.Employee #3 was hired as a counselor on March 14, 2013 and was still in this position at the time of the inspection. Employee #3 was reported to have 1 hour per week devoted to their 1 drug and alcohol client on their caseload.The FTE counselor's caseload calculation is as follows: 1/37.5 = .026 (FTE); 1/.026 = 38.46, which equals to a client/counselor ratio of 38:1.Employee #7 was hired as a counselor on April 1, 2021 and was still in this position at the time of the inspection. Employee #7 was reported to have .75 hours per week devoted to their 1 drug and alcohol client on their caseload.The FTE counselor's caseload calculation is as follows: .75/37.5 = .02 (FTE); 1/.02 = 50, which equals to a client/counselor ratio of 50:1.The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their drug and alcohol clients by the facility ' s workweek (37.5). Then, in order to obtain the counselor's ratio, the total number of clients on the counselor's caseload is divided by the FTE.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Outpatient Supervisor or their designee will ensure counselor caseload ratios do not exceed 35 active clients during primary care hours by maintaining an internal monitoring process that utilizes the department's caseload ratio formula as guidance.
The Outpatient Clinical Supervisor or will review active client caseloads during individual supervision with each clinician for 60 days to ensure client to counselor ratios meet regulatory standards.
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel and training records, the facility failed to document fire extinguisher training, upon staff employment, in five of five applicable personnel records. Staff #1 was hired on February 28, 2022. There was no documentation of fire extinguisher training in personnel record #1.Staff #2 was hired on March 28, 2022. There was no documentation of fire extinguisher training in personnel record #2.Staff #4 was hired on June 6, 2022. There was no documentation of fire extinguisher training in personnel record #4.Staff #5 was hired on October 15, 2022. There was no documentation of fire extinguisher training in personnel record #5.Staff #6 was hired on July 19, 2022. There was no documentation of fire extinguisher training in personnel record #6.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Quality Assurance and Compliance added a "Fire Safety and Emergency Preparedness Training" to the annual Outpatient Training Plan for 2023 for all staff to complete by the corrective action date, which includes fire extinguisher training. The training will be documented in the organization's learning management system.
The "Fire Safety and Emergency Preparedness" training will be added as a required part of the Outpatient Orientation Training Plan for all new hires to complete during their orientation period.
|
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel and training records, the facility failed to document emergency procedures training, upon staff employment, in five of five applicable personnel records. Staff #1 was hired on February 28, 2022. There was no documentation of emergency procedures training in personnel record #1.Staff #2 was hired on March 28, 2022. There was no documentation of emergency procedures training in personnel record #2.Staff #4 was hired on June 6, 2022. There was no documentation of emergency procedures training in personnel record #4.Staff #5 was hired on October 15, 2022. There was no documentation of emergency procedures fire extinguisher training in personnel record #5.Staff #6 was hired on July 19, 2022. There was no documentation of emergency procedures training in personnel record #6.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Quality Assurance and Compliance added a "Fire Safety and Emergency Preparedness Training" to the annual Outpatient Training Plan for all staff to complete by the corrective action date. The training will be documented in the organization's learning management system.
The Director of Quality Assurance and Compliance or their designee will train all outpatient staff on Milestone's Emergency Response Plan specific to their site location.
The "Fire Safety and Emergency Preparedness" training will be added as a required part of the Outpatient Orientation Training Plan for all new hires to complete during their orientation period.
|
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of personnel records, the facility failed to document annual performance evaluations in two of two applicable personnel records.Staff #3 was hired on March 14, 2013. There was no annual performance evaluation documented for 2022 in personnel record #3.Staff #7 was hired on February 29, 2020. There was no annual performance evaluation documented for 2022 in personnel record #7.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Outpatient Program Director and the Outpatient Clinical Supervisor will complete annual written individual staff performance evaluations with each staff member by the corrective action date.
Human Resources will incorporate Outpatient program management into the evaluation reminder process to ensure performance evaluations are completed for all outpatient staff annually.
|
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.
|
Observations
Based on a review of client records, the facility failed to document treatment plan updates at least every 60 days in two of five client records.Client #3 was admitted on February 19, 2019 and is currently an active client. Client #3 had a treatment plan update documented on September 9, 2022. The next treatment plan update was due to be completed by November 9, 2022. The treatment plan update was completed on December 13, 2022.Client #5 was admitted on July 1, 2019 and discharged on December 13, 2022. Client #5 had a treatment plan update documented on August 26, 2022. The next treatment plan update was due to be completed by October 26, 2022. The treatment plan update was completed on December 13, 2022.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Outpatient Clinical Supervisor or their designee will work with clinicians to ensure all treatment plans for active substance use disorder clients are updated according to regulatory standards and will review treatment plan expiration dates during individual supervision with each clinician for 60 days.
The Director of Quality Assurance and Compliance and BH Systems Manager developed an updated face sheet for the outpatient program on the electronic health record (EHR) that includes a "Treatment Plan Expiration Date" module to support clinicians in updating treatment plans.
The BH Systems Manager implemented a new treatment plan specific to substance use disorder clients that includes 60-day treatment plan alerts to support clinicians in updating plans.
|
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
|
Observations
Based on a review of client records, the facility failed to document that counseling services were provided to the client on a regular and scheduled basis in four of five client records.Client #2 was admitted on February 15, 2022 and is currently an active client. The client's last date of treatment was September 12, 2022. No treatment sessions were documented between September 13, 2022 - January 18, 2023.Client #3 was admitted on February 19, 2019 and is currently an active client. The client's last date of treatment was October 21, 2022. No treatment sessions were documented between October 22, 2022 - January 18, 2023.Client #4 was admitted on August 12, 2020 and discharged on January 3, 2023. The client's last date of treatment was August 28, 2022. No treatment sessions were documented between August 29, 2022 - January 3, 2023.Client #5 was admitted on July 1, 2019 and discharged on December 13, 2022. The client's last date of treatment was August 27, 2021. No treatment sessions were documented between August 28, 2021 - December 13, 2022.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Outpatient Supervisor or their designee will work with clinicians to schedule appointments with all active clients within the next 30 days and create and consistent schedule for each client. Client scheduling will be reviewed with each clinician during individual supervision for 60 days.
The Director of Quality Assurance and Compliance and BH Systems Manager developed an updated face sheet for the outpatient program on the electronic health record (EHR) that includes an "Upcoming Appointments" module to support front desk staff in scheduling clients.
|
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.
|
Observations
Based on a review of client records, the facility failed to document follow up contact within 30 days of discharge, as per agency policy, in one of one applicable client record.Client #5 was admitted on July 1, 2019 and discharged on December 13, 2022. There was no 30 day follow up contact documented in client record #5.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Services Office Manager and Outpatient Clinical Supervisor or their designee will complete all missing follow-up information identified in the licensing inspection summary.
The Clinical Outpatient Supervisor will send a monthly outpatient Discharge Report at the start of each month to the Clinical Services Office Manager. The Clinical Services Office Manager or their designee will send follow-up information to each client on the list and document the follow-up in the electronic health record (EHR).
|