INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 28, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of client records, the facility failed to document the name of a person, agency, or organization to whom disclosure is made on consent to release information forms in three of seven client records reviewed.
Client #1 was admitted August 11, 2023 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on August 11, 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 #2 was admitted July 11, 2023 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on July 11, 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 #3 was admitted August 1, 2023 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on August 1, 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 10, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Facility Director will immediately conduct a specific individual training with the Counselor of client #1, #2, & client #3 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 #1, #2, and #3 about the issue and note this in an incidental note with an amended release with specific information since all clients are still active.
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).
|
Observations
Based on a review of client records, the facility failed to document the date of the client ' s signature on a release of information form in one of seven client records reviewed.
Client #1 was admitted August 11, 2023 and was active at the time of inspection. A release of information form to the funding source was in the record; however, the release form did not include the date of when the client signed the form.
This finding was reviewed with facility staff during the licensing process.
|
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 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 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. |
709.92(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.
|
Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans are updated and reviewed at least every 60 days in three of seven client records reviewed.
Client #1 was admitted August 11, 2023 and was active at the time of inspection. The comprehensive treatment plan was completed on October 23, 2023 and a treatment plan update was due no later than December 12, 2023; however, the update was completed on January 14, 2024.
Client #5 was admitted May 22, 2023 and was discharged January 2, 2024. A treatment plan update was completed on October 2, 2023 and the next update was due no later than December 2, 2023; however, the update was completed on December 17, 2023.
Client #6 was admitted June 29, 2023 and was discharged January 17, 2024. A treatment plan update was completed on September 13, 2023 and the next update was due no later than November 13, 2024; however, the update was completed on November 29, 2023.
The findings were reviewed with facility staff during the licensing inspection.
|
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 , # 5, and # 6. Training will be immediate and ongoing. Counselor 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 and clinicians will sign off that they understand the intent of the policy.
An additional staff training session will be conducted on 4/30/24 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 monthly by the Clinical Supervisor to ensure that this standard has been met. |