INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 23, 2025, 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
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
This report is a result of an on-site licensure renewal inspection conducted on January 16, 2025, 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:
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2024 through December 31, 2024 training year, in one of two applicable personnel records reviewed.
Employee # 3 has been in the position of counselor since May 1, 2018. The personnel record documented only 9 hours of annual training during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Prior to inspection, ETHOS counted staff meetings towards clinician training hours; however, after being informed that those hours did not qualify, it resulted in multiple employees being under the 25 hour requirement. Moving forward, ETHOS will no longer utilize staff meeting hours as training hours. Staff has already been informed of this matter and has been enoucraged to obtain as many hours externally as possible.
Additionally, ETHOS has planned monthly internal training hours to cover a variety of training topics (Tuesdays with Tom & Friends) to ensure that employees are still offered internal training hours.
Lastly, ETHOS now has a designed Director of Compliance who will now manage and track all training hours regularly. An audit of training hours will be conducted on a quarterly basis to ensure that employees are aware of their hours and remain on track to meet the training hour requirements. |
705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
|
Observations
Based on a physical plant inspection on January 23, 2025, the facility failed to provide an operable soap dispenser in each bathroom. The soap dispenser in the women ' s restroom was not operable when tested at 11:40 A.M. and 01:45 P.M.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 2/6/2025, this deficiency has been corrected by the buildings maintenance department. To avoid this deficiency in the future, the Site Director will report the issue to the building immediately and also make sure that there are hand soap pumps available to temporarily place in the restrooms when necessary, while waiting for the building maintenance team to fix/replace the soap dispensers.
This will also be checked during routine physical plant walk-throughs completed by the Director of Compliance. |
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.
|
Observations
Based on a review of eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 1 was admitted on June 17, 2024 and was discharged September 11, 2024. The record did not contain a consent to release information form to the funding source; however, there was evidence of billing.
Client # 7 was admitted on October 10, 2024 and was active at the time of the inspection. The consent to release information form to the funding source was not signed until October 25, 2024; however, there was evidence of billing prior to the client signed consent to release information form.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Site Director will immediately conduct a specific individual training with the counselor at this location on importance of timely completion of written consent form for the disclosure of information / releases of information to insurance companies, prior to billing. This includes ensuring that the releases are signed and dated prior to the date items are billed.
This standard will be reinforced at a site specific staff training on the proper way to complete a release of information which will occur within the next 30 days. The Clinical Site Supervisor and the Chief Clinical officer will conduct the training.
The Director of Compliance will randomly conduct chart audits on a monthly basis to ensure that all releases are dated properly. If the Director of Compliance identifies any trends in non-compliance, the Clinical Site Supervisor will be notified to ensure additional training is provided. |
709.92(a) 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:
|
Observations
Based on a review of client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 14 days of admission, per the facility policy, in three of eight records reviewed.
Client # 2 was admitted on July 30, 2024 and was discharged on October 22, 2024. The individual treatment and rehabilitation plan was due to be completed by August 13, 2024; however, it was not completed until August 20, 2024.
Client # 4 was admitted on July 8, 2024 and was discharged on January 5, 2025. The individual treatment and rehabilitation plan was due to be completed by July 22, 2024; however, it was not completed until August 6, 2024.
Client # 5 was admitted on August 5, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by August 19, 2024; however, it was not completed until September 9, 2024.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Compliance met with the Clinical leadership team on 2/10/2025 to determine a plan for ongoing compliance with this regulation.
The Clinical Site Supervisor has met with the clinicians at this site to review ETHOS policy regarding the completion of an initial treatment plan within 14 days of admission. Clinicians were reminded that documentation is considered "completed" based on the date of signature, not the date the document was created. Active client charts were reviewed for compliance and any treatment plans were completed, when necessary.
Starting immediately, the Director of Compliance will audit all charts for all clinicians specifically for treatment plans and treatment plan updates for the next 30 days to ensure all charts are in compliance. The Director of Compliance will identify any trends in non-compliance with the regulations and meet with the team again to reassess the approach and provide additional, if necessary. In addition to the Training Plan audits, the Director of Compliance will complete thorough chart audits for all components on an ongoing basis to ensure continuous compliance.
Additionally, ETHOS will be transitioning to a new EMR which includes a function that enables alerts & reminders to clinicians when they are approaching due dates for required documentation (such as initial treatment plans). ETHOS is confident that this transition will significantly improve compliance with documentation requirements. The anticipated timeframe for implementation of the new EMR is approximately 2nd Quarter 2025. |
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 document treatment plan updates within the regulatory timeframe in three of seven applicable records reviewed.
Client # 4 was admitted on July 8, 2024 and was discharged on January 5, 2025. The individual treatment and rehabilitation plan was completed on August 6, 2024, and the treatment plan update was due no later than October 5, 2024; however, the update was not completed until October 8, 2024. The next treatment plan update was due to be completed by December 7, 2024; however, no additional treatment plan updates were completed prior to discharge.
Client # 6 was admitted on June 14, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 25, 2024, and the treatment plan update was due no later than August 24, 2024; however, the update was not completed until September 9, 2024. The next treatment plan update was due to be completed by November 8, 2024; however, the update was not completed until January 5, 2025.
Client # 8 was admitted on May 23, 2024 and was discharged on January 22, 2025. The individual treatment and rehabilitation plan was completed on May 29, 2024, and the treatment plan update was due no later than July 28, 2024; however, the update was not completed until September 16, 2024.
This is a repeat citation from the March 22, 2024 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
The Director of Compliance met with the Clinical leadership team on 2/10/2025 to determine a plan for ongoing compliance with this regulation.
The Clinical Site Supervisor has met with the clinician for this site to review the citation and reinforce the policy and requirement to complete treatment plan updates every 60 days from the initial treatment plan. Active client charts were reviewed for compliance and any treatment plan updates were completed, when necessary.
Starting immediately, the Director of Compliance will audit all charts for all clinicians specifically for treatment plans and treatment plan updates for the next 30 days to ensure all charts are in compliance. The Director of Compliance will identify any trends in non-compliance with the regulations and meet with the team again to reassess the approach and provide additional, if necessary. In addition to the Training Plan Update audits, the Director of Compliance will complete thorough chart audits for all components on an ongoing basis to ensure continuous compliance.
Additionally, ETHOS will be transitioning to a new EMR which includes a function that enables alerts & reminders to clinicians when they are approaching due dates for required documentation (such as treatment plan updates). ETHOS is confident that this transition will significantly improve compliance with documentation requirements. The anticipated timeframe for implementation of the new EMR is approximately 2nd Quarter 2025. |
709.93(a)(8) 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:
(8) Case consultation notes.
|
Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in three of seven records reviewed. The facility policy manual indicates that case consultation notes will be completed every 90 days.
Client # 4 was admitted on July 8, 2024 and was discharged on January 5, 2025. The second case consultation note was due to be completed by December 25, 2024; however, no additional case consultation notes were documented prior to discharge.
Client # 6 was admitted on June 14, 2024 and was active at the time of the inspection. The first case consultation note was due to be completed by September 12, 2024; however, it was not documented until October 8, 2024.
Client # 8 was admitted on May 23, 2024 and was discharged on January 22, 2025. The first case consultation note was due to be completed by August 21, 2024; however, it was not documented until November 4, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Compliance met with Clinical Leadership on 2/6/2025 to review and make adjustments to the Case Consultation policy. ETHOS Case Consultation policy has been revised to state that consults are required at level of care change. The 90 day requirement has been removed, which would resolve most of these deficiencies. Staff has been alerted of these policy changes and clinical leadership is to meet with all clinical staff within the next 30 days to review the policy in depth and discuss the revised requirement.
Additionally, the Director of Compliance will conduct chart audits weekly, at random, to ensure that the clinicians are complying with the revised policy and the charts include the required Case Consultation documentation any time there is change in a client's level of care (whether that be a step-down or a higher level of care). |
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.
|
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 four of four applicable records reviewed.
Client # 1 was admitted on June 17, 2024 and was discharged September 11, 2024. The record did not contain documentation of follow-up information.
Client # 2 was admitted on July 30, 2024 and was discharged on October 22, 2024. The record did not contain documentation of follow-up information.
Client # 3 was admitted on September 17, 2024 and was discharged on December 11, 2024. The record did not contain documentation of follow-up information.
Client # 4 was admitted on July 8, 2024 and was discharged on January 5, 2025. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Site Director will immediately begin individualized training with the pertinent clinicians on the completion and documentation (via Incidental Note) of follow-up attempts for all discharged clients in a timely manner.
The Director of Compliance will complete thorough chart audits for all documentation components on an ongoing basis to ensure continuous compliance. The Director of Compliance will ensure that the charts of discharged clients are included in the monthly completion of audits to ensure that follow-up attempts are completed and documented. Any identified trends in non-compliance with follow-up completion will be reported to the Clinical Site Director to ensure additional training is completed.
Additionally, ETHOS will be transitioning to a new EMR which includes a function that enables alerts & reminders to clinicians when they are approaching due dates for required documentation (such as follow-up attempts). ETHOS is confident that this transition will significantly improve compliance with documentation requirements. The anticipated timeframe for implementation of the new EMR is approximately 2nd Quarter 2025. |