INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 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:
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Plan of Correction
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of five personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in two records reviewed.
Employee # 3 has been in the position of counselor since March 14, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until May 24, 2024.
Employee # 4 has been in the position of counselor since May 1, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until June 10, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, ETHOS has made the Director of Compliance responsible for completing all fire safety activities during new hire orientation, which is to be completed upon employment.
The Director of Operations has also implemented a form that alerts all pertinent parties of upcoming hires, to ensure plenty of time to schedule necessary orientation/trainings within the required timeframe.
These activities have also been added to the onboarding checklist to ensure the activities have been completed and within the required timeframe. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of five personnel records, the facility failed to ensure that two applicable staff members were trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 3 has been in the position of counselor since March 14, 2024 and is current in that position. Employee # 3 began working shifts on March 14, 2024, but was not trained to perform assigned tasks during emergencies until May 24, 2024.
Employee # 4 has been in the position of counselor since May 1, 2024 and is current in that position. Employee # 4 began working shifts on May 1, 2024, but was not trained to perform assigned tasks during emergencies until June 10, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, ETHOS has made the Director of Compliance responsible for completing a review of all emergency procedure activities & responsibilities during new hire orientation, which is to be completed prior to being on shift.
The Director of Operations has also implemented a form that alerts all pertinent parties of upcoming hires, to ensure plenty of time to schedule necessary orientation/trainings within the required timeframe.
These activities have also been added to the onboarding checklist to ensure the activities have been completed and within the required timeframe. |