INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 23, 2023 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:
|
Plan of Correction
|
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. At the time of the inspection, there was no annual financial audit completed for the facility's fiscal year ending on December 31, 2021.
This is a repeat citation from the March 9, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
ETHOS is in the process of completing a review of Financial Statements by a Certified Public Accounting firm for fiscal year of 2022. This firm is now contracted to complete the same review every year for ETHOS, with the next review for the fiscal year ending 2023 to begin in January of 2024 and to be completed no later than May 30 2024.
ETHOS also has available tax returns, staffing records, payroll records, agreements for third-party reimbursement, and related documents in relation to Fiscal Year 2021 to show good standing throughout the year.
Finally, ETHOS COO has requested an exception to Title 28, Chapter § 709.25 Fiscal Management requirement of the Standards for Licensure of Freestanding Treatment Facilities for the fiscal years ended December 31, 2021 due to the time and financial burden of completing these reviews by the end of the licensing period. In the event the request is denied, ETHOS COO will engage the same CPA firm to prepare a review of financial statements for the fiscal year 2021 to be completed by October 31, 2023. |
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.
|
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 on consent to release information forms in six of seven client records reviewed.
Client # 1 was admitted on August 1, 2022 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the client on June 27, 2022; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 2 was admitted on September 16, 2022 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the client on September 14, 2022; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 3 was admitted on September 6, 2022 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the client on September 6, 2022; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 4 was admitted on October 27, 2022 and was discharged on December 15, 2022. The release of information form to an emergency contact was signed and dated by the client on October 26, 2022; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 5 was admitted on June 29, 2022 and was discharged on August 15, 2022. The release of information form to an emergency contact was signed and dated by the client on June 26, 2022; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 7 was admitted on June 20, 2022 and was discharged on December 16, 2022. The release of information form to an emergency contact was signed and dated by the client on June 20, 2022; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will conduct specific training on importance of completion of written signed completed consent from client for the disclosure of information / releases of information specifically to fully indicating specific information - name of person, agency, or organization to whom the disclosure would be made and critical nature of obtaining all releases singed on date admission or initial evaluation.
The Facility Director will randomly review charts seeing if completing all aspects of releases are in compliance specifically looking at the content named above. All staff training scheduled for 4/26/23 that The Facility Director will conduct. On 4/20/23 the Facility director will meet with all staff related to client #1, #2, #3, #4, #5, and #7 and to review and contact clients to review release of information.
Facility director will follow up on Client #1, #2, #3, #4,# 5 and #7; review with all staff involved regarding the failure of completing these releases of information in the proper manner.
The Facility director will provide individual training on 4/20/23 with all identified staff of the affected charts to review information and state standards and the importance of following our policy and procedure. |
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.
|
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 five applicable client records reviewed.
Client # 3 was admitted on September 6, 2022 and was still active at the time of the inspection. A treatment plan update was completed on December 30, 2022 and the next update was due no later than March 2, 2023; however, the update was not completed until March 17, 2023.
Client # 7 was admitted on June 20, 2022 and was discharged on December 16, 2022. The individual treatment and rehabilitation plan was completed on July 21, 2022 and the first update was due no later than September 21, 2022; however, the update was not completed until January 23, 2023, after the client was discharged.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will complete a staff training on 4/26/23 regarding completion of Treatment Plan Updates in a timely manner. All Staff will agree to complete this training and demonstrate that they understand the intent of this standard.
The Facility Director will meet with specific staff of client charts #3 and #7 and make addition individual instruction by 4/20/23/
The Facility Director will conduct random, monthly chart audits on those counselors to ensure that the standard is met in a timely fashion. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include case consultation notes, in two of five applicable client records reviewed.
Client # 3 was admitted on September 6, 2022 and was still active at the time of the inspection. There were no case consultation notes documented in the record at the time of the inspection.
Client # 7 was admitted on June 20, 2022 and was discharged on December 16, 2022. There were no case consultation notes documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will complete a staff training on 4/26/23 regarding completion of Case Consults in a timely manner. All Staff will agree to complete this training and demonstrate that they understand the intent of this standard.
The Facility Director will meet with specific staff of client charts #3 and #7 and give some addition individual instruction by 4/20/23.
The Facility Director will conduct random, monthly chart audits on those counselors to ensure that the standard is met in a timely fashion and on consistent basis. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of a discharge summary, in two of four applicable client records reviewed.
Client # 5 was admitted on June 29, 2022 and was discharged on August 15, 2022. There was no discharge summary documented in the record at the time of the inspection.
Client # 7 was admitted on June 20, 2022 and was discharged on December 16, 2022. There was no discharge summary documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will complete a staff training on 4/26/23 regarding completion of Discharge Summaries in a timely manner. All Staff will agree to complete this training and demonstrate that they understand the intent of this standard.
The Facility Director will meet with specific staff of client charts #5 and #7 and give some addition individual instruction by 4/20/23.
The Facility Director will conduct random, monthly chart audits on those counselors to ensure that the standard is met in a timely fashion and on a consistent basis. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include documentation of follow-up information, in two of four applicable client records reviewed.
Client # 5 was admitted on June 29, 2022 and was discharged on August 15, 2022. There was no follow-up information documented in the record at the time of the inspection.
Client # 7 was admitted on June 20, 2022 and was discharged on December 16, 2022. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will complete a staff training on 4/26/23 regarding completion of Follow Up Information in a timely manner. All Staff will agree to complete this training and demonstrate that they understand the intent of this standard.
The Facility Director will meet with specific staff of client charts #5 and #7 and give some addition individual instruction by 4/20/23.
The Facility Director will conduct random, monthly chart audits on those counselors to ensure that the standard is met in a timely fashion and on a consistent basis. |