INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2024, 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) (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
Based on a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of seven client records reviewed.
Client # 5 was admitted September 27, 2023 and was discharged January 31, 2024. The release of information form to an emergency contact was signed and dated by the client on September 27, 2023; however, the release form did not include the specific information to be released.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will meet with the counselor of client #5 on 4/9/24 and begin specific training on importance of completion of written signed releases of information specifically related to the type of information that is being released.
The Clinical Supervisor's training will include emphasis on the section of our release that pertains to the information to be released. The Training will occur on 4/16/24.
The clinical supervisor will randomly review charts to ensure that aspects of release are in compliance specifically looking at the section regarding information that is being released.
Chart audits will continue until the counselor is in full compliance. |
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
Based on a review client records, the facility failed to document the purpose of the disclosure on a release of information form in one of seven client records reviewed.
Client # 5 was admitted September 27, 2023 and was discharged January 31, 2024. The release of information form to an emergency contact was signed and dated by the client on September 27, 2023; however, the release form did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will meet individually with the counselor of client #5 on 4/9/24 and begin specific training on importance of completion of written signed releases of information specifically related to include the purpose of the disclosure.
The Clinical Supervisor's site training will include emphasis on the section of our release that pertains to the box indication the purpose of the disclosure. The Training will occur on 4/16/24.
The clinical supervisor will randomly review charts to ensure that aspects of release are in compliance specifically looking at the section regarding the purpose of the disclosure.
Chart audits will continue until the counselor is in full compliance. |