INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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:
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Plan of Correction
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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
The facility failed to document a written policy to address the relapse of recovering clinical personnel and the discipline of nonrecovering employees who abuse alcohol and other drugs.
The policy and procedure manual was reviewed on February 3-4, 2020. There was no documentation of a policy for the above mentioned.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed a policy entitled "Drug-Free Workplace". This policy addresses use in the workplace, reasonable suspicion, reasonable suspicion testing, consequences and return to work for all employees. Policy has been provided to all employees and is available to review on our Intranet site. |
704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The facility failed to document a policy to address the recruitment and hiring of staff persons who are appropriate to the population to be served.
The policy and procedure manual was reviewed on February 3-4, 2020. There was no documentation of policies for the above mentioned.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed a policy entitled "Recruitment and Hiring." This policy addresses All recruitment and hiring practices. It specifically address hiring of persons appropriate to the population served. Policy has been provided to all employees and is available to review on our Intranet site. |
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
The facility failed to document written procedures for the evacuation and transfer of clients and staff to a safe location.
The policy and procedure manual was reviewed on February 3-4, 2020. There was no documentation of procedures for the above mentioned.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Milestone is in the process of developing a policy for the evacuation and transfer of clients and staff to a safe location. Currently, we have evacuation protocols for each facility, but no official policy. Policy will be finalized by 3/31/20. |
705.27 (4) (ii) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
The facility failed to document written procedures for the assignments of staff during emergencies.
The policy and procedure manual was reviewed on February 3-4, 2020. There was no documentation of procedures for the above mentioned.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Milestone is in the process of developing a policy for the evacuation and transfer of clients and staff to a safe location. This policy will also include assignment of staff during the emergency. Currently, we have evacuation protocols for each facility, but no official policy. Policy will be finalized by 3/31/20. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to document the project director annually updated and signed the policy and procedure manual.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual had not been signed by the project director for 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A review form has been created that indicates that the project director has reviewed the policy and procedure manual. A policy has been developed that requires annual review and a signature. |
709.24 (a) LICENSURE Treatment/rehabilitation Management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
The facility failed to document the governing body adopted a written plan for the coordination of client treatment which includes the definition of the target population, identification of treatment models and practices utilized by the facility, written procedures for the management of treatment services, and written procedures for referral outlining cooperation with other providers.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document a written plan which included the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
An "Organizational Description of SUD Outpatient Services" had been previously developed and was approved by the Board of Directors. The description includes the definition of the target population, identification of treatment models and practices utilized by the facility, written procedures for the management if treatment services and written procedures for referral outlining cooperation with other providers. This document is available for review |
709.26 (a) LICENSURE Personnel Management
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
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Observations
The facility failed to document the governing body adopted and implemented written policies and procedures in compliance with State and Federal employment laws which included the utilization of volunteers, supervision of staff, and orientation of new employees.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document policies and procedures which included the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed the following policies: "Staffing", "Individual Supervision", and "Orientation". These policies state that Milestone does not employ volunteers and provides statements regarding compliance with state and federal employment laws. They also provide details regarding regulatory issues of supervision and orientation. These policies have been previously shared with all staff and are available to view on our agency intranet. |
709.28 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
The facility failed to document written procedures developed by the project director which complies with 4 Pa. Code 255.5, which includes the procedure for the confidentiality of client identity and records, the identification of project staff having access to records, and the methods by which staff gain access.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document a written procedure which included the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed a policy entitled "Confidentiality of Consumer/Client Records". This policy addresses general confidentiality concerns, but does not address Substance Use Disorders directly. Milestone is in the process of creating a policy to directly address the confidentiality of client records in our Substance Use Disorder program. The policy will be complete by 3/31/20. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
The facility failed to document and implement a written policy and procedure regarding the use of medications by the client.
The policy and procedures manual was reviewed on February 3-4, 2020. The manual did not document a written policy and procedure which included the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone is in the process of developing a medication policy. Current protocols regarding medication storage and the administration of intra-muscular medication by RNs meet required guidelines, but have not been documented in policy format. The policy will be finalized by April 30, 2020. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to develop policies and procedures to respond to physical assault or sexual assault by staff or a client.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedure for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone is in the process of developing an SUD specific Unusual Incident Reporting policy. The previous Incident Reporting policy did not specifically address physical or sexual assault. The new policy will specify all points related to 709.34. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
The facility failed to develop policies and procedures to respond to selling or use of illicit drugs on the premises.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed a "Drug-Free Workplace" policy. This policy addresses both the use and selling of illicit drugs on the premises. This policy has been shared with all staff and is available for review on the agency intranet. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
The facility failed to develop policies and procedures to respond to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
The facility failed to develop policies and procedures to respond to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
The policy and procedures manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone is in the process of developing a emergency response plan and a business continuity plan. This plan will address disaster response and protocols for agency closure. Plan will be complete by June 1 2020. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
The facility failed to develop policies and procedures to respond to theft, burglary, break-in or similar incident at the facility
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to develop policies and procedures to respond to an event at the facility requiring the presence of police, fire or ambulance personnel.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
The facility failed to develop policies and procedures to respond to a fire or structural damage to the facility.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
The facility failed to develop policies and procedures to respond to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
The facility failed to develop policies and procedures for the documentation of the unusual incident.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
The facility failed to develop policies and procedures for the reporting mechanism to ensure the reporting complies with State and Federal laws.
The policy and procedure manual was reviewed on February 3-4, 2020. The manual did not document the policies and procedures for the above.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Milestone had previously developed an unusual incident reporting policy that did not meet the requirements of 709.34. The new policy will be a specific SUD policy that will contain all requirements of 709.34. This will be finalized by March 31, 2020 |