INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 21, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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) 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 one of seven client records reviewed.
Client #6 was admitted on July 15, 2019 and was discharged April 6, 2020. There was evidence of the billing to an insurance company; however, there was no consent to release information signed by the client prior to the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will begin training on 12/23/2020 and the training on importance of Specifically filling in completely release of information to specific insurance company as well witness signature on Consent to Release document that will be ongoing. The Facility Director will review the Ethos Consent to Release information form to insurance on a monthly basis. All staff will begin training on the importance of filling out full consent and specific insurance on 12/23/2020from 1pm to 3 pm. All sections of the new release will be covered during the training and a review of Confidentiality section 255.5. The Facility Director will conduct monthly, random chart audits to ensure that this standard is being met on all records. |
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
The facility failed to ensure that an informed and voluntary consent to release information form documented the name of the person, agnecy, or organization to whom the disclosure would be made to in one of seven client records reviewed.
Client #7 was admitted on November 6, 2019 and was discharged July 22, 2020. There was a consent to release information form, signed and dated by the client on November 6, 2019, but the form did not include a specific name of the person or agency to whom the disclosure was to be made.
The findings were reviewed with facility staff during the licensing 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 completing all aspects of release prior to the client's signature of release of information at all staff training scheduled for November 25th 2020. Beginning week November 23rd 2020 the facility director will be conducting weekly chart audit reviews to specifically ensure staff completes all confidentiality and fills in all records . On a monthly basis the facility director will review these audits with all staff at treatment team and case conferences to re-enforce compliance with confidentiality and completion of written documentation. The Facility Director has left a message for client # 7 to review concerns and to resolve matter. The Facility Director plans of following up with client # 7 again prior to 11/24/2020 to invite the client to come into review signed document or destroy document as it appeared to not be needed for any additional release of information. |
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
The facility failed to ensure that an informed and voluntary consent to release information form documented the dated signature of a witness on in four of seven client records reviewed.
Client #2 was admitted on November 25, 2019 and was active at the time of inspection. There was a consent to release information form signed and dated by the client on November 25, 2019; however, the form did not include a dated signature of a witness.
Client #5 was admitted on November 12, 2019 and was discharged August 3, 2020. There was a consent to release information form signed and dated by the client on November 12, 2019; however, the form did not include a dated signature of a witness.
Client #6 was admitted on July 15, 2019 and was discharged April 6, 2020. There was a consent to release information form signed and dated by the client on July 15, 2019; however, the form did not include a dated signature of a witness.
Client #7 was admitted on November 6, 2019 and was discharged July 22, 2020. There was a consent to release information form signed and dated by the client on November 6, 2019; however, the form did not include a dated signature of a witness.
The findings were reviewed with facility staff during the licensing 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 indicating specific information to be disclosed (check all areas which apply) and purpose for releasing information (check all areas which apply). The Facility Director will randomly review charts seeing if completing all aspects of release are in compliance. All staff training scheduled for 11/25/2020 and on 12/23/2020 that The Facility Director will conduct. The Facility Director has left a message for client # 5, #2 # 6 and # 7 to review concerns and to resolve matter. The Facility Director plans of following up with all clients again prior to 11/25/2020 to invite the client to come into review signed document. Facility Director will reach out with all Clients this week 11/23/2020 to review releases of information and to have all clients complete areas that were not filled in release. The Facility Director will review with all staff in both trainings, one on 11/25 and one on 12/23/2020 importance of thoroughness of completion of signed released of information. The Facility director will review in case consults monthly and clinical supervision weekly the importance of completion of all areas of release of information.
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