INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that employee #6, a counselor hired on May 1, 2018, received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe, based on a review of the facility's Staffing Requirement Facility Report and the employee's personnel file.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Facility Director received from employee # 6 Documentation of 4 hours of TB/STD on 7/19/19. The Facility Director updated personal file for Employee 6 on that same date. The Facility Director will conduct semi - annual review of personal files especially all new hires this year to make sure all required educational hours are documented. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to ensure that a sufficient number of staff persons were certified in CPR and trained in first aid during the facility's hours of operation.
Based on a review of personnel records and CPR certification cards, the facility provided documentation that only employee had a current CPR certification and 2 employees have had first aid training. The facility's hours of operation are Monday through Friday from 9:00am to 9:00pm. One employee is not sufficient to provide CPR coverage for these hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director met with all staff of West Chester site on Friday 7/19/19 to review POC. All staff are in agreement that CPR and First Aid Trainings are required. Two staff members are already enrolled in September course at YMCA for CPR and First Aid Training. One staff is scheduled in October for First Aid and CPR training as well. The Facility Director will meet with staff on CPR/First AID trainings at end of October 2019 to confirm staff's completion of training hours completion. The Facility Director is taking the online CPR and First Aid training on week of 7/22/19. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure that the hot water temperature in the facility's male and female bathrooms. Based on the physical plant inspection conducted at approximately 3:00pm, both of the bathrooms had a hot water temperature that was measured at 130.4 degrees.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director contacted West Chester building maintenance person on 7/18/19 and put in a work order for the temperature in Men's and women's bathroom to be lowered to under 120 degrees as dictated by the physical plant standards. The Facility Director will document progress on this issue in the maintenance log at the facility until the issue is resolved. The Facility Director and Counselor will inform all clients of the issue and advise use of cold water and/or use of anti-bacterial soap/lotion until the issue has been resolved. The Facility Director will audit temperature monthly after the problem has been resolved to ensure compliance. Facility Director purchased a digital thermometer.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The project failed to provide documentation of an annual financial audit of the activities associated with the project's drug and alcohol abuse services for the project's prior fiscal year.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Facility Director on July 12th, 2019 emailed a signed letter -requesting exemption of annual financial audit on the grounds that this facility and it's company makes less that five hundred thousand dollars a year. The Facility Director emailed this request of exemption to RA-licensuredivision@pa.gov on 7/12/19.
Plan B is we would obtain a public auditor to review fiscal audit in compliance with Annual Financial Audit request. |
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 two of five client records reviewed.
Client #1 was admitted on January 25, 2019 and was discharged on June 20, 2019. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #2 was admitted on December 13, 2018 and was discharged on April 11, 2019. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will develop an automatic release of information to funding sources implemented in all initial intake packets to ensure staff have releases available at intake. The Facility Director will conduct specific training on importance of completion of written signed releases of information to funding sources, what is able to be released on August 14th 2019. The Facility Director has reached out to client # 1 and Client # 2 to review concerns. Client # 1 has responded to the Facility director and plans to come in person to review and sign a release of information for funding sources as client # 1 plans to re-engage in treatment at this site. The Facility director had left a voicemail with Client # 2 on 7/22/19 and will follow up with client # 2 by training day 8/14/19. The Facility director will conduct random chart audits on releases of information, confidentiality, and specific to funding sources between 7/22/19 and 12/10/19 to ensure releases of information are in compliance with Observation :# .0276 |
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 document the name of the person, agency, or organization to whom the disclosure was to be made to on a consent form in one of five client records reviewed.
Client # 3 was admitted on October 23, 2019 and was discharged on April 29, 2019. There was a blank release of information form signed by the client documented in the record.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Observations #: 0277
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 August 14th 2019. Beginning week of 8/14/19 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 # 3 to review concerns and to resolve matter. The Facility Director plans of following up with client # 3 again prior to 8/14/2019 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.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
The facility failed to document the specific information to be disclosed on a consent form in two of five client records reviewed.
Client #3 was admitted on October 23, 2019 and was discharged on April 29, 2019. There was a blank release of information form, signed by the client, documented in the record.
Client #4 was admitted on April 30, 2019 and was still active at the time of the inspection. There was a release of information form to family members, signed by the client on April 16, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Observations #: 0279
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 August 14th 2019 that The Facility Director will conduct. The Facility Director has left a message for client # 3 to review concerns and to resolve matter. The Facility Director plans of following up with client # 3 again prior to 8/14/2019 to invite the client to come into review signed document. Facility Director will reach out with Client # 4 this week 7/22/19 to review releases of information and to have client # 4 complete areas that were not filled in release. The Facility Director will review with all staff on 8/14/19 importance of thoroughness of completion of signed released of information.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of the disclosure on a consent form in two of five client records reviewed.
Client #3 was admitted on October 23, 2019 and was discharged on April 29, 2019. There was a blank release of information form, signed by the client, documented in the record.
Client #4 was admitted on April 30, 2019 and was still active at the time of the inspection. There was a release of information form to family members, signed by the client on April 16, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Observations #: 0281
The Facility Director will conduct specific training on importance of completion of written signed releases of information specifically to fully indicating specific information for 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 August 14th 2019 that The Facility Director will conduct. The Facility Director has left a message for client # 3 to review concerns and to resolve matter. The Facility Director plans of following up with client # 3 again prior to 8/14/2019 to invite the client to come into review signed document. Facility Director will reach out with Client # 4 this week 7/22/19 to review releases of information and to have client # 4 complete purpose for releasing information that were not filled in release. The Facility Director will review with all staff on 8/14/19 importance of thoroughness of completion of signed released of information
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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 document the dated signature of the witness on a consent form in four of five client records reviewed.
Client #1 was admitted on January 25, 2019 and was discharged on June 20, 2019. There was a release of information form to a family member, signed by the client on January 23, 2019.
Client #2 was admitted on December 13, 2018 and was discharged on April 11, 2019. There was a release of information form to a family member, signed by the client on January 15, 2019.
Client #3 was admitted on October 23, 2019 and was discharged on April 29, 2019. There was a blank release of information form, signed by the client, documented in the record.
Client #4 was admitted on April 30, 2019 and was still active at the time of the inspection. There was a release of information form to family members, signed by the client on April 16, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Observations #: 0285
The Facility Director will begin training on 8/14/19 and the training on importance of witness signature on Consent to Release document that will be ongoing. The Facility Director will revise the Ethos Consent to Release information form to include a "Witness" signature line for ALL current and future client that will be included automatically in intake packet. All staff will begin training on the use of new Consent to Release information on 8/14/19 from 1pm to 3 pm. All sections of the new release will be covered during the training and a review of Confidentiality section 255.5. New release forms will be completed on all charts that were identified in the previous audit and included in the client medical records. The Facility Director will conduct monthly, random chart audits to ensure that this standard is being met on all records. The Facility Director has left a message for client # 3 to review concerns and to resolve matter. The Facility Director plans of following up with client # 3 again prior to 8/14/2019. The Facility Director has left a message for client # 1 to review concerns and to resolve matter. The Facility Director plans of following up with client # 1 again prior to 8/14/2019. The Facility Director has left a message for client # 2 to review concerns and to resolve matter. The Facility Director plans of following up with client # 2 again prior to 8/14/2019. Facility Director will reach out with Client # 4 this week 7/22/19 to review releases of information and to have client # 4 complete witness signature section.
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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:
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Observations
The facility failed to document that the individual's comprehensive treatment plan was developed within the timeframe identified in the facility's policy and procedure manual in one of five client records reviewed. Additionally, the facility failed to properly document which type and/or frequency of services the client was to receive on the client's individual treatment plan in two of five client records reviewed.
Client #1 was admitted on January 25, 2019 and was discharged on June 20, 2019. The comprehensive treatment plan was completed on February 1, 2019; however, the plan did not include the type and frequency of services the client was to recieve.
Client #2 was admitted on December 13, 2018 and was discharged on April 11, 2019. The comprehensive treatment plan was completed on February 13, 2019; however, the facility's policy and procedure manual states that the facility would complete the client's comprehensive treatment plan within 14 days of the client's admittance to the facilty.
Client #5 was admitted on March 5, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on March 14, 2019; however, the plan did not include the type of services the client was to recieve.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Observations #: 1875
The Facility Director will begin training immediately and training will be ongoing. The Facility Director and Counselor will attend a mandatory training on 09/18/19 developed by the Project Director. All staff will begin training on the Documentation of Initial Treatment Plan that includes the compliance that the client's comprehensive treatment plan be complete within 14 days of the client's admittance to the facility. Also in this training will be the importance to document which type of services and and/or frequency of services that the client was to receive on the client's individual treatment plan. The Facility Director will conduct monthly, random chart audits to ensure that this standard is being met on all client records. The Facility Director and counselor # 6 will sit with Client # 5 this week on 7/22/19 to review the comprehensive treatment plan was completed on March 14, 2019 and update the plan to include the type of services the client was receiving as well will receive.
Completion Date 10/20/19
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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
The facility failed to provide treatment plan updates within the regulatory timeframe in two of five client records reviewed.
Client #1 was admitted on January 25, 2019 and was discharged on June 20, 2019. The comprehensive treatment plan was completed on February 1, 2019 and the first update was due no later than April 1, 2019. However, the update was not completed until April 29, 2019.
Client #3 was admitted on October 23, 2018 and was discharged on April 29, 2019. The comprehensive treatment plan was completed on October 23, 2018 and the first update was due no later than December 23, 2018. However, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92 Treatment and Rehabilitation Services
Observations #: 1883
The Facility Director will begin training immediately and training day on 9/18/19. The Facility Director and all Counselors of West Chester location will attend a mandatory training on 9/18/19 developed by the Project Director. All staff will begin training on the Documentation of Treatment Plan Updates (completed every 60 days) on 9/18/19 from 9am ? 11am. All sections of the Treatment Plan Update form will be reviewed, including how to identify and "flag" in the Medical Record when the Treatment Plan Update is due. The Facility Director will conduct monthly, random chart audits to ensure that this standard is being met on all client records.
Completion Date 10/20/19
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709.93(a) 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:
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Observations
The facility failed to provide a discharge summary and a progress note in the client's complete record in one of five client records reviewed.
Client #3 was admitted on October 23, 2018 and was discharged on April 29, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Observations #: 1889
The Facility Director will begin training and reviewing of documentation of discharge summaries immediately and training day on 10/02/19. The Facility Director and all Counselors of West Chester location will attend a mandatory training on 10/02/19 developed by the Project Director. All staff will begin training on the Documentation of Discharge Summaries on 10/02/19 from 9am-11am. All sections of the Discharge Summaries form will be reviewed, including importance of aftercare recommendations. On 10/02/19 staff and team will review importance of documentation of aftercare recommendation, referral and exploring client follow up. On a weekly basis the facility director will begin to implement random chart audit reviews as of 8/09/19. The purpose of the chart audit reviews is on a weekly basis to review all charting documentation; specifically all aftercare and discharge notation including progress notation is correct and complete. On a minimum monthly basis, either in case consultation or in treatment team meetings the facility director will report to the staff the findings of the audit and review any non-compliant or incomplete charting will be addressed immediately.
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