INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2024 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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709.28 (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 a person, agency, or organization on consent to release information forms in two of seven client records reviewed.
Client #3 was admitted December 4, 2023 and was active at the time of inspection. A release of information form with a purpose of funding was signed and dated by the client on December 4, 2023; however, the release form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
Client #7 was admitted September 26, 2023 and was discharged December 27, 2023. A release of information form with a purpose of funding was signed and dated by the client on September 26, 2023; however, the release form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
This is a repeat citation from the July 12, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will immediately conduct a specific individual training with the Counselor of client #3 & client #7 on importance of timely completion of written consent form for the disclosure of information / releases of information - to document the specific name of a person, agency, or organization in the ROI.
The counselor will meet with client #3 about the issue and note this in an incidental note with an amended release date noted.
This standard will be reinforced at a site specific staff training on the proper way to complete a release of information which will occur on 4/30/24 at 12:30pm. The Clinical Supervisor will conduct the training.
The Clinical Supervisor of this location will randomly review charts on a monthly basis to ensure that all releases are completed entirely & properly. If a counselor at the this location continues to not meet the standard, then additional individualized trainings will be arranged & instruction repeated on proper way to date a release of information.
Audits will continue monthly until the standard is met by all staff. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the date the client signed the release of information form in one of seven client records reviewed.
Client #1 was admitted September 18, 2023 and was active at the time of inspection. The release of information form to the funding source was signed by the client; however, the release form did not include the date of the client's signature.
This is a repeat citation from the July 12, 2023 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will immediately conduct a specific individual training with the Counselor of client #1 on importance of timely completion of written consent form for the disclosure of information / releases of information - specifically to be aware and vigilant about the date a released is signed. The counselor will meet with client #1 about the date issue and note this in an incidental note with an amended release date noted.
This standard will be reinforced at a site specific staff training on the proper way to complete a release of information which will occur on 4/23/24 at 12:30pm. The Clinical Supervisor will conduct the training.
The Clinical Supervisor of this location will randomly review charts on a monthly basis to ensure that all releases are dated properly. If a counselor at the this location continues to not meet the standard, then additional individualized trainings will be arranged & instruction repeated on proper way to date a release of information.
Audits will continue monthly until the standard is met by all staff. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of all client consent to release information forms were offered to the client in one of seven client records reviewed.
Client #3 was admitted December 4, 2023 and was active at the time of inspection. Release of information forms to the funding source and the emergency contact were signed and dated by the client on December 4, 2023; however, there was no documentation that a copy of both forms were offered to the client.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will immediately conduct a specific individual training with the Counselor of client #3 on importance of completion of written consent form for the disclosure of information / releases of information - specifically to document that the client either accepted or rejected a copy of the ROI.
The counselor will meet with client #3 and offer a copy of the release since this client is still "active". This will be documented in the EMR in the form of an incidental note.
This standard will be reinforced at a site specific staff training on the proper way to complete a release of information which will occur on 4/30/24 at 12:30pm. The Clinical Supervisor will conduct the training.
The Clinical Supervisor of this location will randomly review charts on a monthly basis to ensure that all releases are completed properly and that there is proof a copy was offered to the client. If a counselor at the this location continues to not meet the standard, then additional individualized trainings will be arranged & instruction repeated on proper way to document that a client was offered a copy of a release of information.
Audits will continue monthly until the standard is met by all staff. |
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 ensure treatment plans were reviewed and updated at least every 60 days in three of seven records reviewed.
Client #1 was admitted September 18, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on September 22, 2023 and a treatment plan update was due no later than November 22, 2023; however, the update was not completed until December 20, 2023.
Client #2 was admitted August 23, 2023 and was active at the time of inspection. A treatment plan update was completed on August 31, 2023 and the next update was due no later than October 31, 2023; however, the update was not completed until December 10, 2023.
Client #3 was admitted December 4, 2023 and was active at the time of inspection. A treatment plan update was completed on December 19, 2023 and the next update was due no later than February 19, 2024; however, the update was not completed at the time of the inspection.
This is a repeat citation from the July 12, 2023 annual licensing inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will address documentation concerns regarding timeliness of the completion of the Treatment Plan Updates with the clinician responsible for charting for client #1 , # 2, and # 3. Training will be immediate and ongoing. Counselors will attempt to meet with "active" clients about Tx Plan Update. This will be noted in the chart in the form of an incidental note and amended Treatment Plan Update.
Individualized training for this clinician in this area will occur on 4/16/24 by the Clinical Supervisor and clinicians will sign off that they understand the intent of the policy.
An additional staff training session will be conducted on 4/23/24 at 12:30pm to re-enforce the Treatment Plan update procedures and importance of timeliness of documentation. All staff will be required to attend this additional training.
The Clinical Supervisor will conduct, random monthly chart audits regarding the Treatment Plan Updates and ensure that these will be completed in a timely fashion.
Additional training will be provided bi-weekly by the Clinical Supervisor to ensure that this standard has been met. |