INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 9, 2022, 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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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
Fiscal Management:
The Facility Director 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. The Facility will obtain these services on an annual basis. The facility Director will make available a summary of the annual financial audit for annual inspections in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. The Facility Director should obtain this by April 15th 2022. |
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 obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven client records reviewed.
Client #3 was admitted on December 9, 2021 and was active at the time of inspection. There was evidence of disclosures to the funding source for individual sessions on December 21, 2021; December 23, 2021; and December 28, 2021; however, the consent to release information form to the funding source was not signed by the client until February 7, 2022.
Client #5 was admitted on May 21, 2021 and was discharged on June 9, 2021. There was evidence of a disclosure to the funding source for an individual session on May 21, 2021; however, the consent to release information form to the funding source was not signed by the client until May 28, 2021.
Client #7 was admitted on December 2, 2021 and was discharged on February 22, 2022. There was evidence of a disclosure to the funding source on November 16, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the March 24, 2021 through March 25, 2021 annual licensing renewal inspection.
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Plan of Correction
The Facility Director will conduct specific training on importance of completion of written signed releases of information specifically to fully sign and date at the initial evaluation date. The Facility Director's training will include importance of completion of all record of release of information and signing and dating at initial evaluation. The Training will occur on 5/25/22.
The facility director plans on reviewing critical nature of witness signature, and taking time to be correct on date of signature to be in compliance with admission date or evaluation date of service. The Facility Director will randomly review charts seeing if completing all aspects of release are in compliance specifically looking at dates of services and witness signatures. All staff training scheduled for 5/25/22 that The Facility Director will conduct.
On 3/28/22 The Facility director will meet with the clinician of client # 3 and client # 3 directly to review discrepancy of signing of disclosers and dating of disclosures after facility had discussed with funding source. The Facility director will document in a case consult note the outcome of meeting of the informed understanding to client # 3.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document a dated signature of a witness on release of information forms in two of seven client records reviewed.
Client #6 was admitted on September 14, 2021 and was discharged on November 25, 2021. There was a release of information form to an emergency contact signed by the client on September 8, 2021. However, the signature of the witness was dated on September 7, 2021.
Client #7 was admitted on December 2, 2021 and was discharged on February 22, 2022. There was a release of information form to an emergency contact signed by the client on November 27, 2021. However, the signature of the witness was dated on November 24, 2022.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the March 24, 2021 through March 25, 2021 annual licensing renewal inspection.
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Plan of Correction
The Facility Director will conduct specific training on importance of completion of written signed releases of information specifically to fully sign and date at the initial evaluation date. The Facility Director's training will include importance of completion of all record of release of information and signing and dating at initial evaluation. The Training will occur on 5/25/22.
The facility director plans on reviewing critical nature of witness signature, and taking time to be correct on date of signature to be in compliance with admission date or evaluation date of service. The Facility Director will randomly review charts seeing if completing all aspects of release are in compliance specifically looking at dates of services and witness signatures. All staff training scheduled for 5/25/22 that The Facility Director will conduct. |
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 three of seven client records reviewed.
Client #1 was admitted on September 30, 2021 and was active at the time of inspection. The comprehensive treatment plan was completed on October 10, 2021; 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 January 25, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on February 2, 2022 and included the treatment frequency; however, the plan did not include the type of the treatment and rehabilitation services the client was to receive.
Client #6 was admitted on September 14, 2021 and was discharged on November 25, 2021. The comprehensive treatment plan was completed on September 28, 2021 and included the treatment frequency; however, the plan did not include the type of the treatment and rehabilitation services the client was to receive.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the March 24, 2021 through March 25, 2021 annual licensing renewal inspection.
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Plan of Correction
The Facility Director will begin training immediately and training will be ongoing. Clinical Staff will attend a documentation training on 4/27/22 conducted by The Facility Director. The training will be on Comprehensive Treatment plan and treatment plan updates, specially on documentation of type and frequency of clinical services received at the facility. All sections of the initial and comprehensive treatment plan will be covered and reviewed especially that the counselor document type and frequency of services rendered. The initial treatment plan as well treatment plan updates should include counselor document type and frequency of services rendered. All staff will document that they understand the intent of this regulation.
The Facility Director will conduct monthly, random chart audits to ensure that treatment plan and documentation of counselor document type and frequency of services rendered standard is met on all client records. The facility director plans on implementing additional electronic medical record reminders for this specific comprehensive Treatmemt plan type and frequency requirement.
The Facility Director will meet with the clinician of Client #1 and Client # 2 on 3/30/22. The Purpose of the meeting is to review and update the treatment plans of these to clients to indicate type and frequency in the comprehensive treatment plan. On 4/6/22 the facility director will meet with clinicians of clients#6 to review comprehensive treatment plans of these discharged clients and follow up on importance of documentation of type and frequency of services in outpatient program. |