INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ethos Treatment 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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709.24 (a) (4) 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:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in two of four applicable client records reviewed.
The policy and procedure manual stated that discharge summaries are due within seven days of a client's discharge.
Client #4 was admitted on February 16, 2023, and was discharged on October 27, 2023. There was documentation of a discharge summary being completed for the client; however, the facility staff signature on the summary was dated February 18, 2024 and was outside the facility ' s timeframe noted in the policy manual.
Client #5 was admitted on February 4, 2023, and was discharged on June 25, 2023. There was documentation of a discharge summary being completed for the client; however, the facility staff signature on the summary was dated February 18, 2024 and was outside the facility ' s timeframe noted in the policy manual.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will immediately begin individualized training on the documentation of discharge summaries with the counselors of client #4 & #5. Training will include emphasis on timeliness of documentation of a discharge summary.
The clinical supervisor will conduct a refresher in-service/training on discharge summaries for all staff at this location. The training will be completed on 4/23/24. All sections of the Discharge Summary form will be reviewed, including importance of aftercare recommendations. Special emphasis will be directed towards the timeliness of this documentation.
On a monthly basis the clinical supervisor will conduct random chart audits to ensure that Counselors are compliant with completion of the discharge summary. If counselors at this location continue to struggle, then additional individual coaching sessions will be conducted by the clinical supervisor & identified counselors.
Monthly audits and training will continue until this standard has been met by all counselors.
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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 disclosure is made to on a release of information form in one of seven client records reviewed.
Client #2 was admitted August 21, 2023 and was active at the time of inspection. A release of information form with a purpose of funding was signed and dated by the client on August 21, 2023; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
This is a repeat citation from the March 28, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will immediately conduct a specific individual training with the Counselor of client #2 on importance of timely completion of written consent form for the disclosure of information / releases of information - to document the specific name of a person, agency, or organization in the ROI.
The counselor will meet with client #2 about the issue and note this in an incidental note with an amended release noted since this client is still active.
This standard will be reinforced at a site specific staff training on the proper way to complete a release of information which will occur on 4/23/24 at 12:30pm. The Clinical Supervisor will conduct the training.
The Clinical Supervisor of this location will randomly review charts on a monthly basis to ensure that all releases are completed entirely & properly. If a counselor at the this location continues to not meet the standard, then additional individualized trainings will be arranged & instruction repeated on proper way to date a release of information.
Audits will continue monthly until the standard is met by all staff. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the date the client signed a release of information form in one of seven client records reviewed.
Client #2 was admitted August 21, 2023 and was active at the time of inspection. The release of information form with the purpose of funding did not include the date of when the client signed the release form.
This is a repeat citation from the March 28, 2023 annual licensure renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will immediately conduct a specific individual training with the Counselor of client #2 on importance of timely completion of written consent form for the disclosure of information / releases of information - specifically to be aware and vigilant about the date a released is signed.
This will be reinforced at a West Chester specific staff training on the proper way to complete a release of information which will occur on 4/23/24 at 12:30pm.
The Clinical Supervisor of West Chester will randomly review charts on a monthly basis to ensure that all releases are dated properly. If a counselor at the West Chester location continues to not meet the standard, then additional individualized trainings will be arranged & instruction repeated on proper way to date a release of information.
Audits will continue monthly until the standard is met by all staff.
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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 ensure treatment plans were reviewed and updated at least every 60 days in five of seven client records reviewed.
Client #1 was admitted July 31, 2023 and was active at the time of inspection. A treatment plan update was completed on November 11, 2023 and the next update was due no later than January 11, 2024; however, the update was not completed until January 25, 2024.
Client #2 was admitted August 21, 2023 and was active at the time of inspection. A treatment plan update was completed on October 18, 2023 and the next update was due no later than December 18, 2023; however, the update was not completed until January 9, 2024.
Client #4 was admitted February 8, 2023 and was discharged October 27, 2023. A treatment plan update was completed on June 22, 2023 and the next update was due no later than August 22, 2023; however, the update was not completed until October 16, 2023.
Client# 6 was admitted July 24, 2023 and was discharged January 5, 2024. The comprehensive treatment plan was completed on July 24, 2023 and the first update was due no later than September 24, 2023; however, the update was not completed until October 24, 2023.
Client# 7 was admitted June 1, 2023 and was discharged January 24, 2024. A treatment plan update was completed on September 16, 2023 and the first update was due no later than October 16, 2023; however, the update was not completed prior to the client ' s discharge.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will address documentation concerns regarding timeliness of the completion of the Treatment Plan Updates with the clinician responsible for charting for client #1 , # 4 , #4 , #6, and # 7 on 4/16/24. This will be noted in the chart in the form of an incidental note and amended Treatment Plan Update.
Individualized training for these clinicians in this area will occur on 4/16/24 and clinicians will sign off that they understand the intent of the policy.
An additional staff training session will be conducted on 4/23/24 at 12:30pm to re-enforce the Treatment Plan update procedures and importance of timeliness of documentation. All staff will be required to attend this additional training.
The Facility Director will conduct, random monthly chart audits regarding the Treatment Plan Updates and ensure that these will be completed in a timely fashion. Additional training will be provided monthly by the Clinical Supervisor to ensure that this standard has been met. |