INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3, 2026 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document a written individual training plan annually for each employee, which is to be developed with input from both the employee and the supervisor, in nine of nine applicable personnel records reviewed.
Employee # 1 was hired as the project director on October 10, 2012. The individual training plan was completed on January 2, 2026; however, there was no documentation indicating the training plan was developed with input from the supervisor.
Employee # 2 was hired as the facility director on October 10, 2012. The individual training plan was completed on January 2, 2026; however, there was no documentation indicating the training plan was developed with input from the supervisor.
Employee # 3 was hired as the clinical supervisor on March 10, 2021. The individual training plan was completed on January 2, 2026; however, there was no documentation indicating the training plan was developed with input from the supervisor.
Employee # 4 was hired as a counselor on March 10, 2021. The individual training plan was completed on January 2, 2026; however, there was no documentation indicating the training plan was developed with input from the supervisor.
Employee # 5 was hired as a counselor on March 10, 2021. The individual training plan was completed on January 2, 2026; however, there was no documentation indicating the training plan was developed with input from the supervisor.
Employee # 6 was hired as a counselor on March 10, 2021. The individual training plan was completed on January 2, 2026; however, there was no documentation indicating the training plan was developed with input from the supervisor.
Employee # 7 was hired as a counselor on October 12, 2021. The individual training plan was completed on January 2, 2026; however, there was no documentation indicating the training plan was developed with input from the supervisor.
Employee # 8 was hired as a counselor on June 20, 2023. There was documentation of a 2026 individual training plan; however, there was no documentation indicating the training plan was developed with input from both the employee and the supervisor.
Employee # 9 was hired as a counselor on July 23, 2025. The individual training plan was completed on January 2, 2026; however, there was no documentation indicating the training plan was developed with input from the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has reviewed all staff individual training plans for missing inputs.
On 06/24/26 the Facility director met with supervisors and re-emphasized the requirement to provide their feedback and input to the staff during the annual training plan developments. The missing and not documented inputs from the direct report staff in annual plans were also addressed in the meeting. The Facility Director explained the requirement to document supervisors and staff feedbacks and inputs in annual training plans.
In next 30 days supervisors will meet with the staff to complete the input section of the annual training plans.
The Facility director will review annual training plans in 30 days to make sure missing inputs from supervisors and staff are complete and documented.
Upon completions of the upcoming annual staff development meetings the Facility director will be responsible to review annual training plans to ensure supervisors and staff inputs are documented. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in two of seven client records reviewed.
Client # 1 was admitted on January 10, 2026 and was still active at the time of the inspection. There was a blank release of information form signed by the client on January 10, 2026; however, the form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
Client # 3 was admitted on February 20, 2026 and was still active at the time of the inspection. There was a release of information form to a family member signed by the client on February 25, 2026; however, the form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made.
This is a repeat citation from the June 12, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has reviewed informed and voluntary consent forms to identify instances where the name of the person or organization to whom disclosure was made was missing.
On 06/24/26 the Facility Director had a meeting with the clinical staff to inform about noncompliance with $709.28 and address the performance of the clinical staff who failed to include the name or organization who whom disclosure was made.
The therapist called the client #1 on 07/06/26 to gather the information to whom the disclosure was made. On 07/06/26 the consent form was updated to include the documentation of the organization to which the disclosure was made.
The therapist called the client #3 on 07/07/26 to gather the information to whom the disclosure was made. On 07/07/26 the consent form was updated to include the documentation of the organization to which the disclosure was made.
The Clinical supervisor will review clinical records monthly for any new informed and voluntary forms completed going forward to ensure that the section with the name or organization to whom disclosure was made to is complete.
The Facility Director will monitor the Supervisors' review and will conduct an additional check of the informed and voluntary forms monthly. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in six of seven client records reviewed.
Client # 1 was admitted on January 10, 2026 and was still active at the time of the inspection. There was a blank release of information form signed by the client on January 10, 2026; however, the form did not include documentation of the specific information to be disclosed.
Client # 2 was admitted on September 22, 2025 and was still active at the time of the inspection. There was a release of information form to a family member signed by the client on September 23, 2025; however, the form did not include documentation of the specific information to be disclosed.
Client # 3 was admitted on February 20, 2026 and was still active at the time of the inspection. There was a release of information form to a family member signed by the client on September 23, 2025; however, the form did not include documentation of the specific information to be disclosed.
Client # 4 was admitted on November 8, 2025 and was discharged on February 16, 2026. There was a release of information form to a family member signed by the client on November 18, 2025; however, the form did not include documentation of the specific information to be disclosed.
Client # 5 was admitted on September 18, 2025 and was discharged on January 13, 2026. There was a release of information form to a family member signed by the client on September 18, 2025; however, the form did not include documentation of the specific information to be disclosed.
Client # 6 was admitted on November 25, 2025 and was discharged on January 13, 2026. There was a release of information form to a family member signed by the client on November 25, 2025; however, the form did not include documentation of the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has reviewed informed and voluntary consent forms to identify instances where the specific information to be disclosed was missing.
On 06/24/26 the Facility Director had a meeting with the clinical staff to inform about noncompliance with $709.28 and address the performance of the clinical staff who failed to include the specific information to be disclosed on the consent form.
The therapist called the client #1 on 07/06/26 to confirm the information to be disclosed. On 07/06/26 the consent form was updated to include the documentation of the specific information to be disclosed.
The therapist will reach out the client #2 to confirm the information to be disclosed. The consent form will be updated to include the documentation of the specific information to be disclosed by 07/20/2026.
The therapist called the client #3 on 07/07/26 to confirm the information to be disclosed. On 07/07/26 the consent form was updated to include the documentation of the specific information to be disclosed.
The Clinical supervisor will review clinical records monthly for any new informed and voluntary forms completed going forward to ensure that the section with the specific information to be disclosed is complete.
The Facility Director will monitor the Supervisors' review and will conduct an additional check of the informed and voluntary forms monthly.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in six of seven client records reviewed.
Client # 1 was admitted on January 10, 2026 and was still active at the time of the inspection. There was a blank release of information form signed by the client on January 10, 2026; however, the form did not include documentation of the purpose of the disclosure.
Client # 2 was admitted on September 22, 2025 and was still active at the time of the inspection. There was a release of information form to a family member signed by the client on September 23, 2025; however, the form did not include documentation of the purpose of the disclosure.
Client # 3 was admitted on February 20, 2026 and was still active at the time of the inspection. There was a release of information form to a family member signed by the client on September 23, 2025; however, the form did not include documentation of the purpose of the disclosure.
Client # 4 was admitted on November 8, 2025 and was discharged on February 16, 2026. There were release of information forms to a family member and a doctor signed by the client on November 18, 2025; however, the form did not include documentation of the purpose of the disclosure.
Client # 5 was admitted on September 18, 2025 and was discharged on January 13, 2026. There was a release of information form to a family member signed by the client on September 18, 2025; however, the form did not include documentation of the purpose of the disclosure.
Client # 6 was admitted on November 25, 2025 and was discharged on January 13, 2026. There were release of information forms to a family member and a doctor signed by the client on November 18, 2025; however, the form did not include documentation of the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has reviewed informed and voluntary consent forms to identify instances where the documentation of the purpose of the disclosure was missing.
On 06/24/26 the Facility Director had a meeting with the clinical staff to inform about noncompliance with $709.28 and address the performance of the clinical staff who failed to include the documentation of the purpose of the disclosure.
The therapist called the client #1 on 07/06/26 to document the purpose of the disclosure. On 07/06/26 the consent form was updated to include the documentation of the purpose of the disclosure.
The therapist will reach out to the client #2 to document the purpose of the disclosure. The consent form will be updated to include the documentation of the purpose of the disclosure by 07/20/2026.
The therapist called the client #3 on 07/07/26 to document the purpose of the disclosure. On 07/07/26 the consent form was updated to include the documentation of the purpose of the disclosure.
The Clinical supervisor will review clinical records monthly for any new informed and voluntary forms completed going forward to ensure that the section with the information of the purpose of the disclosure is complete.
The Facility Director will monitor the Supervisors' review and will conduct an additional check of the informed and voluntary forms monthly.
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