INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 16, 2025, 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room, as an individual session in the second office on the left could be heard in the furthermost office on the left, which is the neighboring office, between 10:15 a.m. and 10:45 a.m. on January 16, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ETHOS Leadership had immediately provided this location with additional sound machines to ensure privacy of counseling sessions. As of January 17, 2025, machines were placed in appropriate offices to ensure compliance with this regulation.
During regular physical plant walk-throughs, the Director of Compliance and/or Clinical Leadership will check to make sure that all offices continue to have functioning equipment and resources to ensure client privacy during counseling sessions. |
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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 6 was admitted on September 19, 2024 and was active at the time of the inspection. There was evidence of disclosures to a family member during a family counseling session on November 21, 2024; however, the consent to release information form to the family member signed by the client on September 19, 2024, did not allow for the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Site Director will immediately conduct a specific individual training with the counselor at this location on the purpose and importance of ensuring that the consent to release information includes the disclosure of information. The counselor was also reminded of their responsibility to check for completed & accurate consents before beginning sessions with new clients, including any family sessions, as well as before disclosing any information to any additional parties.
This standard will be reinforced at a site specific staff training on the proper way to complete a release of information which will occur within the next 30 days. The Clinical Site Supervisor and the Chief Clinical officer will conduct the training.
The Director of Compliance will randomly conduct chart audits on a monthly basis to ensure that all releases are dated properly. If the Director of Compliance identifies any trends in non-compliance, the Clinical Site Supervisor will be notified to ensure additional training is provided. |
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 document treatment plan updates within the regulatory timeframe in five of five applicable records reviewed.
Client # 1 was admitted on July 1, 2024 and was discharged on September 18, 2024. The individual treatment and rehabilitation plan was completed on July 9, 2024, and the treatment plan update was due no later than September 7, 2024; no treatment plan updates were completed prior to discharge.
Client # 2 was admitted on August 12, 2024 and was discharged on December 23, 2024. The individual treatment and rehabilitation plan was completed on August 12, 2024, and the treatment plan update was due no later than October 11, 2024; however, no treatment plan updates were completed prior to discharge.
Client # 3 was admitted on June 7, 2024 and was discharged on November 11, 2024 The individual treatment and rehabilitation plan was completed on June 21, 2024, and the treatment plan update was due no later than August 20, 2024; however, the update was not completed until September 4, 2024. The next treatment plan update was due to be completed by November 3, 2024; however, no treatment plan updates were completed prior to discharge.
Client # 5 was transferred from another program within the facility on July 9, 2024 and was active at the time of the inspection. The most recent treatment plan prior to transferring the other program was completed on April 18, 2024. The treatment plan was not updated until September 16, 2024. The next treatment plan update was due to be completed by November 15, 2024; however, no treatment plan updates were completed prior to the inspection.
Client # 6 was admitted on September 19, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 20, 2024, and the treatment plan update was due no later than November 19, 2024; however, no treatment plan updates were completed prior to the inspection.
This is a repeat citation from the July 12, 2023 and March 25, 2024 annual licensing renewal inspections.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance met with the Clinical leadership team on 2/10/2025 to determine a plan for ongoing compliance with this regulation.
The Clinical Site Supervisor has met with the clinician for this site to review the citation and reinforce the policy and requirement to complete treatment plan updates every 60 days from the initial treatment plan. Active client charts were reviewed for compliance and any treatment plan updates were completed, when necessary.
Starting immediately, the Director of Compliance will audit all charts for all clinicians specifically for treatment plans and treatment plan updates for the next 30 days to ensure all charts are in compliance. The Director of Compliance will identify any trends in non-compliance with the regulations and meet with the team again to reassess the approach and provide additional, if necessary. In addition to the Training Plan Update audits, the Director of Compliance will complete thorough chart audits for all components on an ongoing basis to ensure continuous compliance.
Additionally, ETHOS will be transitioning to a new EMR which includes a function that enables alerts & reminders to clinicians when they are approaching due dates for required documentation (such as treatment plan updates). ETHOS is confident that this transition will significantly improve compliance with documentation requirements. The anticipated timeframe for implementation of the new EMR is approximately 2nd Quarter 2025. |
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.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in three of four applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed every 90 days.
Client # 2 was admitted on August 12, 2024 and was discharged on December 23, 2024. The record did not contain case consultation notes.
Client # 5 was transferred from another program within the facility on July 9, 2024 and was active at the time of the inspection. The record did not contain case consultation notes.
Client # 6 was admitted on September 19, 2024 and was active at the time of the inspection. The record did not contain case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance met with Clinical Leadership on 2/6/2025 to review and make adjustments to the Case Consultation policy. ETHOS Case Consultation policy has been revised to state that consults are required at level of care change. The 90 day requirement has been removed, which would resolve most of these deficiencies. Staff has been alerted of these policy changes and clinical leadership is to meet with all clinical staff within the next 30 days to review the policy in depth and discuss the revised requirement.
Additionally, the Director of Compliance will conduct chart audits weekly, at random, to ensure that the clinicians are complying with the revised policy and the charts include the required Case Consultation documentation any time there is change in a client's level of care (whether that be a step-down or a higher level of care). |
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 August 12, 2024 and was discharged on December 23, 2024. The record did not contain documentation of follow-up information.
Client # 4 was admitted on May 22, 2024 and was discharged on August 2, 2024. The 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 Clinical Site Director will immediately begin individualized training with the pertinent clinicians on the completion and documentation (via Incidental Note) of follow-up attempts for all discharged clients in a timely manner.
The Director of Compliance will complete thorough chart audits for all documentation components on an ongoing basis to ensure continuous compliance. The Director of Compliance will ensure that the charts of discharged clients are included in the monthly completion of audits to ensure that follow-up attempts are completed and documented. Any identified trends in non-compliance with follow-up completion will be reported to the Clinical Site Director to ensure additional training is completed.
Additionally, ETHOS will be transitioning to a new EMR which includes a function that enables alerts & reminders to clinicians when they are approaching due dates for required documentation (such as follow-up attempts). ETHOS is confident that this transition will significantly improve compliance with documentation requirements. The anticipated timeframe for implementation of the new EMR is approximately 2nd Quarter 2025. |
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.
A plan of correction to ensure treatment and rehabilitation plans were updated at least every 60 days was submitted and approved by the Department for the July 12, 2023, and March 25, 2024, annual licensing inspections. Treatment plan updates completed every 60 days was again found to be a deficiency in the January 16, 2025, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ETHOS has recently appointed someone as the Director of Compliance, who will now oversee that all requirements are met and all Plans of Corrections are implemented and ongoing compliance is met.
The Director of Compliance will be responsible for completing regular chart audits, auditing each clinician at least monthly. The Director of Compliance will identify any trends in non-compliance or any trending issues and make adjustments as needed to ensure compliance with the Plans of Corrections. |