This report is a result of an on-site licensure renewal inspection conducted on December 20, 2024, 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:
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Plan of Correction
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Observations
Based on a review of client records, the facility failed to document follow-up information in one of one applicable discharged record.
The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 30 days.
Client #2 was admitted on May 5, 2023, and was discharged on May 14, 2024. There was no follow-up documented in client #2 ' s record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The deficiency relates to an inactive client chart. The program is currently not capable of seeing new clients due to lack of staff.
The follow up note is already in the system and if/when the program reopens it will be used to document all communications with the client within 30 days after they are discharged. This procedure will be discussed with all staff as part of their new hire onboarding.
Staff will be shown where the follow up document is, shown how to call and speak with the client to check in on how they are doing, then provide documentation about how the client is doing since being discharged from the program within 30 days of discharge.
The Outpatient Supervisor, Director, or Senior Director will alert the staff of the follow up document and the need for the staff to reach out to the person to follow up after they have discharged from the program.
The follow up form will be used once the program has started back up to reach out and check on how the client is doing after they have been discharged.
The follow up document will be used when all clients are discharged from the program moving forward. The program will review the procedure for this with current staff by March 14th, 2025.
Outpatient supervisor, Director, or Senior director will complete random monthly audits of chart to check that this is staying compliant. |