INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 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:
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Plan of Correction
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of four personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one of one applicable record reviewed.
Employee # 4 was hired as a counselor on April 13, 2023 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until June 26, 2023.
This is a repeat citation from the September 19, 2022 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director met with employee #4 on 7/26/23 and reviewed the training on use of a fire extinguisher. The original fire safety orientation was completed and signed by the counselor with retraining date included.
The Clinical Supervisor will meet with all new employees of the Collegeville office within one week of hire date to ensure that use of a fire extinguisher is reviewed and understood.
Random safety compliance audits will be completed on a monthly basis moving forward to ensure that this training is not missed for any new hire. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and a discussion with facility staff, the facility failed to ensure that one applicable staff was trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 4 was hired as a counselor on April 13, 2023 and is current in that position. Employee # 4 began working shifts in May 2023 but was not trained to perform assigned tasks during emergencies until June 26, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director met with employee #4 on 7/26/23 and reviewed the training on emergency protocols. The original emergency protocol orientation was completed and signed by the counselor with retraining date included.
The Clinical Supervisor will meet with all new employees of the Collegeville office within one week of hire date to ensure that all emergency protocols are reviewed and understood.
Random safety compliance audits will be completed on a monthly basis moving forward to ensure that this training is not missed for any new hire. |
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.
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Observations
Based on an administrative review, the project 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, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Ethos Treatment LLC has contracted with the independent accounting firm of Morris J Cohen & Co, PC for fiscal year audits of 2021 & 2022. As of the date of this inspection, both audits were still in progress as documented by a letter from them dated 6/26/23. A financial review with financial statements and balance sheets was completed for fiscal year 2022 by Morris J Cohen & Co, PC and presented to the State in June of 2023. We are aware now that this was not sufficient because the language did not imply an "Audit" was completed.
For all future audits moving forward, the contract will be assigned in January of the upcoming fiscal year. The Facility Director is responsible to ensure that the contract is assigned in January.
Unfortunately we have no control over when these audits are completed, as they are independent from our organization.
The Facility Director and President of Ethos Governing Body are meeting weekly regarding progress with both audits. If an exception is needed for the 2022 audit, the Facility Director will file on 8/25/23, if auditor appears to not be able to meet 9/1/23 deadline.
Upon full receipt of the complete 2022 audit, The Facility Director will submit to review to the state for their approval . |
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 three of seven client records reviewed.
Client # 1 was admitted on October 20, 2022 and was discharged on April 28, 2023. There was evidence of disclosures to a family member during a family counseling session on December 17, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure. Additionally, the consent to release information form to the funding source was signed by the client on November 1, 2022; however, the record contained evidence of billing prior to the client ' s signed consent form.
Client # 2 was admitted on November 7, 2022 and was discharged on March 20, 2023. There was evidence of disclosures to a family member during a family counseling session on December 12, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 5 was admitted on December 29, 2022 and was discharged on June 12, 2023. There was evidence of disclosures to a family member during a family counseling session on March 15, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
This is a repeat citation from the September 19, 2022 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 of Collegeville met with counselor on 7/26/23 to review guidelines and standards regarding completion of releases for family members included in family counseling sessions.
The Clinical Supervisor of Collegeville will randomly review charts seeing if staff is completing all aspects of releases with a focus on family members of enrolled clients.
Facility Director will follow up on all affected charts (#1,2 and 5) review with the counselor involved regarding the failure of completing these releases of information in the proper manner. Also, all active records will be reviewed for similar issues and appropriate consents will be reviewed and signed by clients if necessary.
The Facility director and/or clinical supervisor will provide ongoing, individual training for staff members who remain in non-compliance as a result of monthly audits. |
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 consent to release information forms in six of seven client records reviewed.
Client # 1 was admitted on October 20, 2022 and was discharged on April 28, 2023. The release of information form to an emergency contact was signed and dated by the client on November 1, 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 November 7, 2022 and was discharged on March 20, 2023. The release of information form to an emergency contact was signed and dated by the client on November 5, 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 June 8, 2023 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 November 5, 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 December 29, 2022 and was discharged on June 12, 2023. The release of information form to an emergency contact was signed and dated by the client on December 23, 2022; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 6 was admitted on January 23, 2023 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 January 23, 2023; 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 March 28, 2023 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 April 10, 2023; 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.
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Plan of Correction
The Facility Director has contacted our software company as of 7/19/23 and made changes to the EMR to include 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 as part of the client portal system. This software glitch was recognized prior to the visit, but was unable to be upgraded at the time of the inspection.
Training on the new EMR system regarding completion of releases will begin on 7/26/23. All staff will be trained on portal responsibilities and manual entry procedures, if needed. The primary counselor will be responsible moving forward for all needed releases.
The Facility Director and/or Clinical Supervisor will randomly review charts seeing if staff is completing all aspects of releases.
Facility director will follow up on all affected charts (#1,2,3,5,6, and 7) review with all counselors involved regarding the failure of completing these releases of information in the proper manner.
The Facility director and/or clinical supervisor will provide ongoing, individual training for staff members who remain in non-compliance as a result of monthly audits. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one applicable record reviewed.
Client #4 was admitted on January 3, 2023 and was involuntarily discharged on February 1, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director did address documentation concerns regarding timeliness of the completion of the involuntary termination notification with the clinician responsible for charting for client #4 on 7/20/23. This will be noted in the chart in the form of an incidental note and the counselor will inform the client in writing of discharge status.
Individualized training for this counselor in this area will occur on 7/26/23 and the counselor will sign off that they understand the intent of the policy/standard.
The Clinical Supervisor of the Collegeville office will conduct, random monthly chart audits regarding the process of notifying clients of involuntary termination, if applicable and ensure that these will be completed in accordance with the standard.
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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.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information, in two of four applicable records reviewed.
Client # 2 was admitted on November 7, 2022 and was discharged on March 20, 2023. The client record did not contain documentation of follow-up information.
Client #4 was admitted on January 3, 2023 and was discharged on February 1, 2023. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director did address documentation concerns regarding timeliness of the completion of the 7 day follow-up attempt documentation with the clinician responsible for charting for client #2 and #4 on 7/20/23. This will be noted in the chart in the form of an incidental note and amended follow-up attempt.
Individualized training for these clinicians in this area will occur on 7/26/23 and clinicians will sign off that they understand the intent of the policy/standard.
The Clinical Supervisor of the Collegeville office will conduct, random monthly chart audits regarding the follow-up information 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. |