INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29, 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 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 obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven client records reviewed.
Client #2 was admitted on January 9, 2023 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 #6 was admitted on November 15, 2022 and was discharged on February 28, 2023. 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 #7 was admitted on August 30, 2022 and was discharged on May 22, 2023. 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. Additionally, there was documentation of disclosures to a government agency on August 30, 2022 and November 14, 2022; 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 July 7, 2022 and August 5, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project procedure to obtain a written informed and voluntary consent from the client for the disclosure of information contained in client records was reviewed by the project director to make sure it includes the requirement to obtain the signed consent form prior to the disclosure.
In the all staff meeting on 07/19/2023 the project director conducted the training to the staff on the requirement to obtain the written and voluntary consent form from the client prior to the disclosure.
The Client #2 was contacted by the clinical supervisor on 07/05/2023 and requested to sign the consent to release information form required for the disclosures. The client #2 stop by on 07/10/2023 to complete the consent to release of information form. The form was filed in the client records.
The Project Director and Clinical supervisor will review clinical records weekly to assure that the staff obtains the written informed and voluntary consent from clients for the disclosure of information in clients records.
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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 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 five of six applicable client records reviewed.
Client #1 was admitted on June 22, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on June 22, 2022 and the first update was due no later than August 22, 2022; however, the update was completed on December 8, 2022.
Client #2 was admitted on January 9, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on January 9, 2023, and the first update was due no later than March 9, 2023; however, the update was completed on March 15, 2023. Additionally, a treatment plan update was completed on March 15, 2023, and the next update was due no later than May 15, 2023; however, the update was completed on June 22, 2023.
Client #4 was admitted on October 28, 2022 and was discharged on March 16, 2023. The comprehensive treatment plan was completed on October 28, 2022, and the first update was due no later than December 28, 2022; however, the update was completed on January 26, 2023.
Client #5 was admitted on December 29, 2022 and was discharged on May 15, 2023. A treatment plan update was completed on March 1, 2023, and the next update was due no later than May 1, 2023; however, the update was not completed prior to discharge.
Client #7 was admitted on August 30, 2022 and was discharged on May 22, 2023. The comprehensive treatment plan was completed on August 30, 2022, and the first update was due no later than October 30, 2022; however, the update was completed on November 18, 2022.
This is a repeat citation from the July 7, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project had procedure to review and update treatment plans every 60 days with client signatures. There was an incorrect assumption that the client should be present during the review. Therefore there were times when 60 days reviews treatment plans reviews were completed late.
In the staff meeting on 07/19/2023 the project director addressed the requirement to review and update treatment plans every 60 days even if the client is not present. Staff was informed and trained on this requirement and the procedure was documented in Policies and Procedures manual. The Memo on the requirement was signed by each clinical staff.
The Project Director and Clinical supervisor will monitor the compliance with the regulation to review and update treatment plans every 60 days bi-weekly. |
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 obtaining 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 July 7, 2022 and August 5, 2021 annual licensing inspections. Obtaining 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 29, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will monitor the implementation of the Plan of Correction.
The Project Director and the Clinical supervisor will review all active clients clinical file to make sure all steps outlined in prior and the current Plans of correction are complete. The deadline to complete the review is 08/31/2023
The Project Director will be responsible for ensuring that the facility is in compliance with regulations outlined in $709.28 related to the informed and voluntary consent to release of information.
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