INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 12, 2025 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's June 2024 through May 2025 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's posted hours of operation are Monday through Friday from 8am to 8pm and Saturday from 8am to 5pm.
Every fire drill conducted during the reviewed period were completed during the weekdays and all between the hours of 12:20pm and 2:15pm. There were no morning, evening, or Saturday fire drills conducted during the reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and his designee will be conducting fire drills at different times, different shifts, including morning and evening hours and on different days.
Effective immediately the Facility Director will be responsible to schedule fire drills at different times and on different days and will monitor the fire drill log monthly to comply with the regulation 705.28. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 4 was admitted on October 9, 2024 and was discharged on January 14, 2025. There was evidence 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 any of the disclosures.
This is a repeat citation from the August 5, 2021, July 7, 2022, June 29, 2023, and June 11, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has reviewed and addressed the instance when the informed and voluntary consent to release of information prior to the disclosure wasn't complete with the staff on 06/20/2025.
The clinical documentation of the staff member who failed to complete the an informed and voluntary form will be reviewed weekly by the clinical supervisor.
The Clinical supervisor will provide an additional training and reminder to all clinician on the Milestone Rehabilitation Confidentiality Policy and regulations 709.28 in the next all staff meeting.
The Facility Director will be monitor the completion of the training and weekly reviews.
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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 one of seven client records reviewed.
Client # 6 was admitted on February 20, 2025 and was discharged on April 14, 2025. A release of information form to a family member was signed by the client on February 20, 2025; however, the form did not include documentation of the name of the person, agency, or organization to whom the disclosure would be made to.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has reviewed the licensing survey results and the required information to include in a consent to release information form with the staff on 06/20/25.
The Clinical supervisor will provide an additional training on the Confidentiality policy as it relates to a Consent to release of information form to all clinician in the next all staff meeting.
The Facility Director will be monitor the completion of the training. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admission dates and discharge dates within a specific time period.
Upon request, the facility was unable to produce client lists which is to include admission dates and discharge dates. Additionally, while the Licensing Representative was onsite, facility staff had to review every client record manually to find the client records that were within the review period requested.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Milestone Rehabilitation has recently developed the electronic health record system. The management continues to make adjustments and improvements to its functionality and reports.
The Facility Director has requested the EHR developer to add the fields and functionality that enables to report the data in parameters required by the regulation 709.31. Specifically, the reporting system will include dates of admissions and dates of discharges.
Facility Director will be responsible for the completion of the modification. The expected date of the completion is 08/31/2025 |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of seven client records reviewed.
Client # 2 was admitted on April 7, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 7, 2025; however, the plan did not include the frequency of treatment and rehabilitation services.
Client # 4 was admitted on October 9, 2024 and was discharged on January 14, 2025. The individual treatment and rehabilitation plan was completed on October 9, 2024; however, the plan did not include the frequency of treatment and rehabilitation services.
Client # 5 was admitted on November 12, 2024 and was discharged on May 6, 2025. The individual treatment and rehabilitation plan was completed on November 12, 2024; however, the plan did not include the frequency of treatment and rehabilitation services.
Client # 6 was admitted on February 20, 2025 and was discharged on April 14, 2025. The individual treatment and rehabilitation plan was completed on February 20, 2025; however, the plan did not include the frequency of treatment and rehabilitation services.
Client # 7 was admitted on December 27, 2024 and was discharged on January 24, 2025. The individual treatment and rehabilitation plan was completed on December 27, 2024; however, the plan did not include the frequency of treatment and rehabilitation services.
This is a repeat citation from the June 11, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Milestone Rehabilitation has the policy to include types and frequencies of treatments and rehabilitation services.
The Facility Director will review the deficiency with the staff on 07/21/2025. The Clinical supervisor will conduct an additional training on 07/21/2025 on how to document frequencies in the clinical documentation.
The clinical supervisor will be responsible to review treatment plans monthly and will make sure that the frequency of treatments and rehabilitation services are included in treatment plans in accordance with the regulation 709.92. |
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 review and update treatment and rehabilitation plans at least every sixty days in two of three applicable client records reviewed.
Client # 2 was admitted on April 7, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 7, 2025 and an update was due no later than June 6, 2025; however, the update was not completed until June 11, 2025.
Client # 5 was admitted on November 12, 2024 and was discharged on May 6, 2025. The individual treatment and rehabilitation plan was completed on November 12, 2024 and an update was due no later than January 11, 2025; however, the update was not completed until January 24, 2025.
This is a repeat citation from the July 7, 2022, June 29, 2023, and June 11, 2024 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Milestone Rehabilitation has the policy to review and update treatment and rehabilitation plans every 60 days.
If the client is not available for the 60 days review and updates of the treatment and rehabilitation plan the clinical staff will complete the review and update without the client and will attach the progress note to document the absence of the client and expected date to follow up.
The Facility Director will re-train the staff on the process on 07/21/2025.
The clinical supervisor will be reviewing all treatment and rehabilitation plans that are due 60 days updates to ensure all plans reviews and updates are completed with and without clients present and the progress notes are attached where applicable. |
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 failing to obtain 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 August 5, 2021, July 7, 2022, June 29, 2023, and June 11, 2024 annual licensing inspections. Failing to obtain 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 12, 2025 licensing inspection.
Plans of correction for failing to review and update treatment and rehabilitation plans at least every sixty days were submitted and approved by the Department for the July 7, 2022, June 29, 2023, and June 11, 2024 annual licensing inspections. Failing to review and update treatment and rehabilitation plans at least every sixty days was again found to be a deficiency in the June 12, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will be responsible to monitor the full implementation of the plan of correction.
Informed and Voluntary Consent forms prior to the disclosure of the information will be reviewed weekly by the Clinical Supervisor to ensure it is completed in its full entirely and prior to the disclosure of the information. Reg $709.28
The Clinical Supervisor will monitor the completion of review and updates of 60 days treatment and rehabilitation plans to make sure timely development and appropriate documentation is attached as necessary. Reg $709.92
The Facility Director will be responsible to address repeated deficiencies and make sure there will be no more repeated citations. |