INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9, 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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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).
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in one record reviewed.
Client # 6 was admitted on July 11, 2024 and was active at the time of the inspection. The record contained a consent to release information form to the funding source dated March 11, 2024, however it did not contain the client's signature.
This is a repeat citation from the March 26, 2024 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/6/2025, all consent forms for this client have been signed by the client.
The Clinical Site Director has met with this specific counselor to conduct 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 - specifically to be aware and vigilant about ensuring all components of the release is signed and dated. The counselor was also reminded of their responsibility to check for completed consents before beginning sessions with new clients, as well as before disclosing any information to any additional parties.
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(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 document treatment plan updates within the regulatory timeframe in seven of seven applicable records reviewed.
Client # 1 was admitted on July 1, 2024 and was discharged on December 4, 2024. The individual treatment and rehabilitation plan was completed on July 15, 2024, and the treatment plan update was due no later than September 13, 2024; however, no treatment plan updates were completed prior to discharge.
Client # 2 was admitted on April 8, 2024 and was discharged on October 28, 2024. The individual treatment and rehabilitation plan was completed on April 15, 2024, and the treatment plan update was due no later than June 14, 2024; however, the update was not completed until June 17, 2024. The next treatment plan update was due to be completed by August 16, 2024; however, it was not completed until September 1, 2024.
Client # 3 was admitted on May 9, 2024 and was discharged on December 5, 2024. The individual treatment and rehabilitation plan was completed on May 23, 2024, and the treatment plan update was due no later than July 22, 2024; however, the update was not completed until July 29, 2024. The next treatment plan update was due to be completed by September 27, 2024; however, it was not completed until October 4, 2024.
Client # 4 was admitted on July 11, 2024 and was discharged on November 21, 2024. The individual treatment and rehabilitation plan was completed on July 18, 2024, and the treatment plan update was due no later than September 16, 2024; however, the update was not completed until September 26, 2024.
Client # 5 was admitted on August 26, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 1, 2024, and the treatment plan update was due no later than October 31, 2024; however, the update was not completed until November 8, 2024. The next treatment plan update was due to be completed by January 7, 2025; however, no treatment plan update was completed prior to the date of the inspection.
Client # 6 was admitted on July 11, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 18, 2024, and the treatment plan update was due no later than September 16, 2024; however, the update was not completed until September 26, 2024. The next treatment plan update was due to be completed by November 25, 2024; however, it was not completed until December 2, 2024.
Client # 7 was admitted on September 3, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 16, 2024, and the treatment plan update was due no later than November 15, 2024; however, the update was not completed until November 21, 2024.
These findings were discussed with facility staff during the licensing process.
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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 within 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.
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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 # 2 was admitted on April 8, 2024 and was discharged on October 28, 2024. The case consultation note was not documented until July 15, 2024.
Client # 3 was admitted on May 9, 2024 and was discharged on December 5, 2024. The first case consultation was not documented until August 19, 2024.
Client # 5 was admitted on August 26, 2024 and was active at the time of the inspection. The case consultation note was not documented until December 2, 2024.
These findings were reviewed with facility staff during the licensing process.
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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 Cose 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.
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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 four applicable records reviewed.
Client # 1 was admitted on July 1, 2024 and was discharged on December 4, 2024. The record did not contain documentation of follow-up information.
Client # 2 was admitted on April 8, 2024 and was discharged on October 28, 2024. The record did not contain documentation of follow-up information.
Client # 4 was admitted on July 11, 2024 and was discharged on November 21, 2024. The 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 Clinical Site Director will immediately begin individualized training with this specific clinician on the completion and documentation (via Incidental Note) of follow-up attempts for all discharged clients.
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. |