INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2019 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 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential 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
The facility failed to ensure that each fire extinguisher in the facility was inspected annually, based upon observation during the physical plant inspection.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
All fire extinguishers at the facility have been replaced and the inspection has been called for. The completion expected date is 08/22/2019
The Project Director will be responsible to schedule annual inspections of extinguishers. Due dates of inspections will be attached to the records and documentation related to facilities premises, posted on the administrative office board and set up in the electronic scheduler. |
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 that the project director had prepared, annually updated and signed the facility's written manual, which delineates the project policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has filed the documentation that the Project Director has prepared, updated and signed the facility's written manual of the project policies and procedures.
The Project Director will be responsible to document, attach and sign any updates and revisions as they occur and sign the facility policy and procedure manual annually. |
709.32 (c) (1) (i) - (ii) 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:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
The project failed to include and implement a written medication policy and procedure that addresses the "Administration of medication, including the documentation of the administration of medication when self-administered by the client."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director among with the Medical Director have developed and implemented the Medication Policy and Procedure regarding Administration of medications, including the documentation of the administration of medications self-administered by clients.
The Project Director is responsible to implement the Medication Policy and Procedure regarding the Administration of medications. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
The project failed to include and implement a written medication policy and procedure that addresses the "Inspection of storage areas that ensures compliance with State and Federal laws and program policy. This policy must include, but not be limited to, disinfectants and drugs for external use are stored separately from oral and injectable drugs."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Policies and Procedures have been added to include Policies and Procedures that outline inspection of storage areas that ensures compliance with State and Federal laws, including disinfectants and drugs for external use to be stored separately from oral and injectable drugs. Such Policies and Procedures have been implemented effective 08/05/2019.
The project Director is responsible for the monitoring and compliance with these policies |
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 include and implement in their unusual incident policies and procedures the facility's response to the selling or use of illicit drugs on the premises.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual incident policy and procedure in response to the selling or use drugs on the premises have been developed and implemented effective 08/11/2019.
The Project Director is responsible for the oversight and compliance with these Policy and Procedure. |
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 include and implement in their unusual incident policies and procedures the facility's response to the significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual incident policy and procedure in response to the significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence which closes the facility for more than 1 day, have been developed and implemented effective 08/11/2019.
The Project Director is responsible for the oversight and compliance with these Policy and Procedure. |
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 include and implement in their unusual incident policies and procedures the facility's response to the theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual incident policy and procedure in response to the theft, burglary, break-ins or similar incident at the facility, have been developed and implemented effective 08/11/2019.
The Project Director is responsible for the oversight and compliance with these Policy and Procedure. |
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 include and implement in their unusual incident policies and procedures the facility's response to an event at the facility that requires the presence of police, fire, or ambulance personnel.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual incident policy and procedure in response to am event at the facility that requires the presence of police, fire, or ambulance personnel, have been developed and implemented effective 08/11/2019.
The Project Director is responsible for the oversight and compliance with these Policy and Procedure. |
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 include and implement in their unusual incident policies and procedures the facility's response to the outbreak of a contagious disease which requires the notificaiton to the Centers for Disease Control (CDC).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual incident policy and procedure in response to the outbreak of a contagious disease which requires the notification to the Center for Disease Control, have been developed and implemented effective 08/11/2019.
The Project Director is responsible for the oversight and compliance with these Policy and Procedure. |
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 and implement policies and procedures that included the documentation of the unusual incident.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual incident policy and procedure have been developed to include the documentation of the unusual incident. These policy and procedure has implemented effective 08/11/2019.
The Project Director is responsible for the oversight and compliance with these Policy and Procedure. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
The facility failed to develop and implement policies and procedures that included the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual incident policy and procedure have been developed and implemented to include the prompt review and identification of the causes directly and indirectly responsible for the unusual incident.
The Project Director is responsible for the oversight and compliance with these Policy and Procedure. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The facility failed to develop and implement policies and procedures that included the implementation of a timely and appropriate corrective action plan, when indicated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual incident policy and procedure have been developed and implemented to include a timely and appropriate corrective action plan. The effective date is 08/11/2019.
The Project Director is responsible for the oversight and compliance with these Policy and Procedure. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to develop and implement policies and procedures that included the ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual incident policy and procedure have been developed and implemented to include the ongoing monitoring of the corrective action plan effective 08/11/2019.
The Project Director is responsible for the oversight and compliance with these Policy and Procedure. |
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 and implement policies and procedures that included the reporting mechanism that ensures that the reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Unusual incident policy and procedure have been developed and implemented to include the reporting mechanism that ensures that the reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The effective date is 08/11/2019.
The Project Director is responsible for the oversight and compliance with these Policy and Procedure. |