INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 7, 2021 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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704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of personnel records, the facility failed to ensure that at least half of each employee ' s training during the facility ' s January 1, 2020 through December 31 2020 training year was provided by trainers not directly employed by the project in one out of five applicable records reviewed.
Employee #1 was hired as a project director on September 15, 2018. The personnel record documented the required 12 hours of training; however, all 12 hours documented were provided by individuals employed within the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will immediately review the training hours required with all employees of this site. The facility director plans to address quarterly with the staff the annual educational plans in addition to the annual plan. The facility director on a quarterly basis review with all clinical staff that it is required to receive trainings provided by trainers not directly employed by the project. The facility director immediately will encourage/request all staff to seek out over 12 hours a year outside of ETHOS providing training hours. The facility director will partner will outside provider to come in to provide training in last quarter of year if staff has not met requirement. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training during the facility's January 1, 2020 through December 31, 2020 training year in three of four applicable records reviewed.
Employee #2 was hired as a counselor on May 1, 2018. The personnel record documented 22.25 hours of training.
Employee #3 was hired as a counselor on December 3, 2018. The personnel record documented 12 hours of training.
Employee #5 was hired as a counselor on November 15, 2019. The personnel record documented 8 hours of training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will immediately review the training hours required with all employees of this site.Employee # 2, Employee #3 and Employee # 5 has already met state and policy requirements for 2021 to ensure this will not be an issue in future. The facility director plans to address quarterly with the staff the annual educational plans in addition to the annual plan. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the January 2020 through March 2021 fire drill log, the facility failed to conduct unannounced monthly fire drills for the months of November and December of 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has submitted a "special exemption request letter" to the state as there was limited access to the building at that time. The facility director plans to review monthly fire drill logs with the staff as per our policy and procedure. (Letter sent on 4/19/21). If this special circumstance letter is denied the facility director will plan on submitting a second letter. IF that letter is denied then the facility director will meet with building management to ensure that there is full access to building to conduct unannounced monthly fire drill with staff.
The Facility Director will meet monthly with this staff to review fire drill safety and conduct monthly unannounced fire drills and document accordingly resuming on 4/22/21. On a quarterly basis the facility director will review all fire drill logs to ensure that documentation is up to date.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility ' s January 2020 through March 2021 fire drill log, the facility failed to set off the fire alarm or a smoke detector during each monthly fire drill conducted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director immediately submitted a special request letter to the state as we are requesting that an ETHOS staff member initiates a fire drill as the smoke detector system is wired into the building and would directly impact other tenants in the building.(Letter sent on 4/19/21). If this letter is rejected by state then the facility director will meet with building management to review how to facilitate fire alarms and not interrupt other tenants in the building.
The facility director plans to review monthly fire drill logs with the staff as per our policy and procedure.If the letter is rejected the facility director plans to resubmit and request a review. If the 2nd letter is rejected then the facility director will reach out to the building and review options to facilitate a random fire drill in building that does not effect other tenants.
The Facility Director will meet monthly with this staff to review fire drill safety and conduct monthly unannounced fire drills (utilizing a hand held smoke detector if approved) and document accordingly resuming on 4/23/21.
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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 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.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility director will meet on 4/20/21 with owners and board of ETHOS on 4/20/21 to review and request obtaining an independent accounting firm to review and facilitate an independent annual audit. The plan is the facility director should have one in place by 5/26/21. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in the client's individual treatment and rehabilitation plan in five of seven client records reviewed.
Client #1 was admitted on October 29, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed on November 9, 2020; however, the plan did not include the type and frequency of the treatment and rehabilitation services the client was to receive.
Client #2 was admitted on November 17, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed on November 30, 2020; however, the plan did not include the type and frequency of the treatment and rehabilitation services the client was to receive.
Client #3 was admitted on December 17, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed on December 28, 2020; however, the plan did not include the type and frequency of the treatment and rehabilitation services the client was to receive.
Client #5 was admitted on December 7, 2020 and was discharged on February 23, 2021. The comprehensive treatment plan was completed on December 10, 2020; however, the plan did not include the type and frequency of the treatment and rehabilitation services the client was to receive.
Client #6 was admitted on August 13, 2020 and was discharged on December 21, 2020. The comprehensive treatment plan was completed on August 18, 2020; however, the plan did not include the type and frequency of the treatment and rehabilitation services the client was to receive.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will begin training on 4/20/21 immediately and training will be ongoing. Clinical Staff will attend a documentation training on the timeliness of treatment plan on 05/05/21. All sections of the treatment plan update will be covered and reviewed, including timeliness, goals, and type and frequency requirements. All staff will document that they understand the intent of this regulation especially documenting the type and frequency of treatment and rehabilitation services in the client's individual treatment and rehabilitation plan. On 5/5/21 The facility director will review client #2, #6 ad # 7 with clinical team to review their treatment plan updates in charts and educate on importance of treatment plan updates in clinical chart.
The Facility Director will conduct monthly, random chart audits to ensure that this standard is met on all client records.
The Facility Director will conduct monthly, random chart audits to ensure that this standard is met on all client records- Client # 2 will be reviewed on that date with primary employee on case as well Client # 1, client # 3 and Client # 5. |
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 a maintain a complete client record on an individual, which includes follow-up information in two of four applicable client records reviewed.
Client #4 was admitted to outpatient level of care on September 8, 2020 and discharged on November 11, 2020; however, there was no documentation of follow-up information.
Client #7 was admitted to outpatient level of care on July 23, 2020 and discharged on November 12, 2020; however, there was no 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 will begin training immediately and training will be ongoing. Clinical Staff will attend an importance documentation of follow up after discharge and client outcome studies on 6/30/21. The documentation of follow up after discharge on client # 7 and Client # 4 will be reviewed on 4/20/21 with primary employee's involved with cases. All staff will document that they understand the intent of this regulation.
The Facility Director will conduct monthly, random chart audits to ensure that this standard is met on all client record |