INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure that the hot water temperature in the men's bathroom did not exceed 120 degrees Fahrenheit as it was observed, on August 16, 2018 at approximately 2:00 p.m., that the temperature was measured at 136 degrees Fahrenheit.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.24 Bathrooms
The Facility Director has already addressed West Chester building maintenance person immediately, a work order for the temperature in Men's bathroom to be lowered to under 120 degrees as dictated by the physical plant standards. The Facility Director has documented in a new maintenance log that the issue is resolved. The Facility Director will audit temperature monthly to ensure compliance.
Completion Date 8/31/ 18
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document whether the fire alarm or smoke detector was operative during each fire drill for the reviewed time period of September 2017 through July 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 Fire Safety
The Project Director will develop a new fire drill log which includes a column that states whether smoke detector is "Operational". The Facility Director and Counselor of the location will be trained on 8/29/18 staff meeting regarding the use of the new form for all fire drills. The Facility Director will audit new form on a monthly basis to ensure it has been used moving forward for all fire drills.
Completion Date 8/29/18
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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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed. Additionally, the facility failed to document the witness signature on every client record reviewed and there were four of seven client records that had various consent to release information forms that were missing other required elements.
Client # 1 was admitted on May 2, 2018 and was active at the time of the inspection. There was documentation of correspondence with an insurance provider on May 17 2018 and on July 11, 2018; however, there was no consent to release information form on file prior to disclosure. Additionally, all of the consent forms in the record were missing witness signatures.
Client # 2 was admitted on May 31, 2018 and was active at the time of the inspection. There were two consent to release information forms to the insurance provider and a community agency; however, both consents contained illegible expiration and signature dates. Additionally, all of the consent forms in the record were missing witness signatures.
Client # 3 was admitted on January 16, 2018 and was active at the time of the inspection. There was a consent to release information form to an insurance provider signed and dated on January 16, 2018; however, the consent listed one of the items to be disclosed as " other " with no specification of what would be released. Additionally, all of the consent forms in the record were missing witness signatures.
Client # 4 was admitted on February 12, 2018 and was discharged on April 17, 2018. All the consent forms in the record were missing witness signatures.
Client # 5 was admitted on May 21, 2018 and was discharged on July 24, 2018. There was a consent to release information form to a judge signed and dated on May 21, 2018; however, the form failed to include the expiration date, purpose for disclosure and items to be disclosed. Additionally, all the consent forms in the record were missing witness signatures.
Client # 6 was admitted on April 3, 2018 and was discharged on June 4, 2018. There were two consent to release information forms to the insurance provider and an individual; however, both consents contained illegible expiration and signature dates. Additionally, the consent to release information form to the insurance provider failed to include the purpose for disclosure and listed " other " with no specification of what would be released. Finally, all of the consent forms in the record were missing witness signatures.
Client # 7 was admitted on February 26, 2018 and was discharged on June 4, 2018. There was correspondence with a family member on July 10, 2018; however, there was no consent to release information form on file prior to disclosure. Additionally, all the consent forms in the record were missing witness signatures.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.28 Confidentiality
The Facility Director will begin training immediately and training will be ongoing. The Facility Director will revise the Ethos Consent to Release information form to include a "Witness" signature line. All staff will begin training on the use of new Consent to Release information on 9/5/18 from 1pm to 3 pm. All sections of the new release will be covered during the training and a review of Confidentiality section 255.5. New release forms will be completed on all charts that were identified in the previous audit and included in the client medical records. The Facility Director will conduct monthly, random chart audits to ensure that this standard is being met on all records.
Completion Date 10/16/18
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to include documentation verifying written acknowledgement by clients that they had been informed of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records and the right to submit rebuttal data or memoranda to their own records, in every client record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.30 Client Rights
The Facility Director will develop a new section on the Client Treatment Consent Form which includes wording specific to "the client has been informed of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records and the right to submit rebuttal data or memoranda to their own records". The Facility Director and Counselor will attend a mandatory training on 9/5/18 developed by the Project Director. All staff will begin training on the Documentation and use of this new form on 9/5/18 from 1pm to 3 pm. The Facility Director and Counselor will meet with all active clients on 9/10/18 and inform them of their rights and document in medical record. The Facility Director will conduct monthly, random chart audits to ensure that this standard is being met on all client records.
Completion Date 10/16/18
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
The facility failed to include in the intake and admission process, documentation of a complete medical history, drug and alcohol history, and/or personal history in three of seven client records.
Client # 3 was admitted on January 16, 2018 and was active at the time of the inspection.
Client # 4 was admitted on February 12, 2018 and was discharged on April 17, 2018.
Client # 5 was admitted on May 21, 2018 and was discharged on July 24, 2018.
Client # 7 was admitted on February 26, 2018 and was discharged on June 4, 2018.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
709.91 Intake and Admission
The Facility Director will begin training immediately and training will be ongoing. The Facility Director and Counselor will attend a mandatory training on 9/5/18 developed by the Project Director. All staff will begin training on the Documentation of Histories, including: Medical History, Drug & Alcohol History, and Personal History on 9/5/18 from 1pm to 3 pm. All sections of the Intake History form will be reviewed, including how to scan all pages of this document in the Medical Record. The Counselor for client #3 will review & update the History and put the amended document in the medical record before 10/1/18. The Facility Director will conduct monthly, random chart audits to ensure that this standard is being met on all client records.
Completion Date 10/16/18
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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
The facility failed to provide treatment plan updates within the regulatory timeframe in three of three applicable client records reviewed.
Client # 1 was admitted on May 2, 2018 and was active at the time of the inspection. The comprehensive treatment plan was completed on May 31, 2018 and the first update was due no later than July 31, 2018. However, there was no update on file as of the date of the inspection.
Client # 3 was admitted on January 16, 2018 and was active at the time of the inspection.
The comprehensive treatment plan was completed on January 30, 2018 and the first update was due no later than March 16, 2018. However, the update was not completed until April 16, 2018.
Client # 7 was admitted on February 26, 2018 and was discharged on June 4, 2018. The comprehensive treatment plan was completed on March 5, 2018 and the first update was due no later than May 5, 2018. However, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92 Treatment and Rehabilitation Services
The Facility Director will begin training immediately and training will be ongoing. The Facility Director and Counselor will attend a mandatory training on 9/5/18 developed by the Project Director. All staff will begin training on the Documentation of Treatment Plan Updates (completed every 60 days) on 9/5/18 from 1pm to 3 pm. All sections of the Treatment Plan Update form will be reviewed, including how to flag in the Medical Record when the Treatment Plan Update is due. The Counselor for client #1, #3, and #7 will complete Treatment plan update and put the document in the medical record by 10/1/18. The Facility Director will conduct monthly, random chart audits to ensure that this standard is being met on all client records.
Completion Date 10/16/18
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