INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 12, 2023, 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) 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 complete an informed and voluntary consent to release information form prior to the disclosure of information in two of seven records reviewed.
Client # 6 was admitted on February 17, 2023 and was active at the time of the inspection. The record did not contain a client signed consent to release information form to the funding source; however, the record contained evidence of billing.
Client # 7 was admitted on March 13, 2023 and was active at the time of the inspection. There was evidence of disclosures to a family member during an intake session on March 13, 2023, and a phone call on March 30, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director of Collegeville met with counselor on 7/26/23 to review guidelines and standards regarding completion of releases for funding sources & family members included in family counseling sessions.
The Clinical Supervisor of Jenkintown will randomly review active charts seeing if staff is completing all aspects of releases with a focus on funding sources and family members of enrolled clients.
Facility Director will follow up on all affected charts (#6 and 7) review with the counselor involved regarding the failure of completing these releases of information in the appropriate manner. Also, all active records will be reviewed for similar issues and appropriate consents will be reviewed and signed by clients if necessary.
The Facility director and/or clinical supervisor will provide ongoing, individual training for staff members who remain in non-compliance as a result of monthly audits. |
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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in writing that included the name of the person, agency, or organization to whom disclosure is made in six of seven records reviewed.
Client # 1 was admitted on January 6, 2023 and was discharged on April 8, 2023. The release of information form to an emergency contact was signed and dated by the client on January 5, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 2 was admitted on December 26, 2022 and was discharged on April 19, 2023. The release of information form to an emergency contact was signed and dated by the client on December 22, 2022; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 3 was admitted on January 9, 2023 and was discharged on April 19, 2023. The release of information form to an emergency contact was signed and dated by the client on January 5, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 4 was admitted on April 24, 2023 and was discharged on June 26, 2023. The release of information form to an emergency contact was signed and dated by the client on May 1, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 5 was admitted on December 14, 2022 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the client on February 14, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
Client # 7 was admitted on March 13, 2023 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the client on March 13, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has contacted our software company as of 7/19/23 and made changes to the EMR to include signed completed consent from client for the disclosure of information / releases of information specifically to fully indicating specific information - name of person, agency, or organization to whom the disclosure would be made as part of the client portal system. This software glitch was recognized prior to the visit, but was unable to be upgraded at the time of the inspection.
Training on the new EMR system regarding completion of releases will begin on 7/26/23. All staff will be trained on portal responsibilities and manual entry procedures, if needed. The primary counselor will be responsible moving forward for all needed releases.
The Facility Director and/or Clinical Supervisor will randomly review charts seeing if staff is completing all aspects of releases.
Facility director will follow up on all affected charts (#1,2,3,4,5 and 7) review with all counselors involved regarding the failure of completing these releases of information in the proper manner. All active files will be reviewed for similar issues and signed by client as necessary
The Facility director and/or clinical supervisor will provide ongoing, individual training for staff members who remain in non-compliance as a result of monthly audits. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the date, event, or condition upon which the consent will expire in one record reviewed.
Client # 5 was admitted on December 14, 2022 and was still active at the time of the inspection. The record contained a consent to release information form to an employer signed by the client on December 14, 2022, that was missing the date, event, or condition upon which the consent will expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has contacted our software company as of 7/19/23 and made changes to the EMR to include auto-filled end date (or termination date one year from the date the release has been signed) as part of the client portal system. This software glitch was recognized prior to the visit, but was unable to be upgraded at the time of the inspection.
Training on the new EMR feature regarding "termination/end date" of releases will begin on 7/26/23. All staff will be trained on portal responsibilities and manual entry procedures, if needed. The primary counselor will be responsible moving forward for all needed releases.
The Facility Director and/or Clinical Supervisor will randomly review charts each month seeing if staff is completing the section regarding the expiration date of the release.
Facility Director will follow up on all affected charts (for client #5) review with the counselor involved regarding the failure of completing and reviewing these releases of information in the proper manner. Also, all current active charts will be reviewed and consents signed by the client as is appropriate.
The Facility director and/or clinical supervisor will provide ongoing, individual training for staff members who remain in non-compliance as a result of monthly audits. |
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 on the individual treatment and rehabilitation plan in five of seven client records reviewed.
Client # 1 was admitted on January 6, 2023 and was discharged on April 8, 2023. The individual treatment and rehabilitation plan was completed on January 22, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 2 was admitted on December 26, 2022 and was discharged on April 19, 2023. The individual treatment and rehabilitation plan was completed on January 2, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on January 9, 2023 and was discharged on April 19, 2023. The individual treatment and rehabilitation plan was completed on January 22, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 5 was admitted on December 14, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 2, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on February 17, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 20, 2023; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will address documentation concerns regarding timeliness of the completion of the Individual Treatment Plan - specifically around type and frequency of services with the clinician responsible for charting for client #1,#2, #3, #5, and #6 on 7/26/23.
The New EMR system implemented in May 2023 features a new Treatment Plan form which has a section specifically highlighting Type and Frequency of services rendered and is auto-filled at evaluation. This new version has corrected this issue; unfortunately the charts observed were prior to implementation.
Individualized training for the clinicians impacted in this area has occurred on 7/26/23 and clinicians will sign off that they understand the intent of the policy.
The Clinical Supervisor of Jenkintown office will conduct, random monthly chart audits regarding the Individual Treatment Plans and ensure that these will be completed in an accurate, timely fashion. Additional training will be provided monthly by the Clinical Supervisor to ensure that this standard has been met prior to 8/25/23. |
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 review and update treatment and rehabilitation plans at least every sixty days in two of five applicable client records reviewed.
Client # 2 was admitted on December 26, 2022 and was discharged on April 19, 2023. The individual treatment and rehabilitation plan was completed on January 2, 2023, and the first update was due no later than March 2, 2023; however, no updates were completed prior to the date of discharge.
Client # 3 was admitted on January 9, 2023 and was discharged on April 19, 2023. The individual treatment and rehabilitation plan was completed on January 22, 2023, and the first update was due no later than March 22, 2023; however, the update was not completed until April 17, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director did address documentation concerns regarding timeliness of the completion of the Treatment Plan Updates with the clinician responsible for charting for client #2 & #3 on 7/20/23. This will be noted in the chart in the form of an incidental note and placed in the record.
Individualized training for these clinicians in this area will occur on 7/26/23 and clinicians will sign off that they understand the intent of the policy.
The Clinical Supervisor of the Jenkintown office 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 |
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 ensure a complete client record included information relative to the client's involvement with the project to include follow-up information, in three of three applicable records reviewed.
Client # 2 was admitted on December 26, 2022 and was discharged on April 19, 2023. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on January 9, 2023 and was discharged on April 19, 2023. The client record did not contain documentation of follow-up information.
Client # 4 was admitted on April 24, 2023 and was discharged on June 26, 2023. The client record did not contain 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 did address documentation concerns regarding timeliness of the completion of the 7 day follow-up attempt documentation with the clinician responsible for charting for client #2, #3 and #4 on 7/20/23. This will be noted in the chart in the form of an incidental note.
Individualized training for these clinicians in this area did occur on 7/26/23 and clinicians did sign off that they understand the intent of the policy/standard.
The Clinical Supervisor of the Jenkintown office will conduct, random monthly chart audits regarding the follow-up information 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. |