INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 31, 2021 through April 1, 2021 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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704.11(c)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of personnel records, the facility failed to ensure that at least half of each employee ' s training during the facility ' s January 1, 2020 through December 31 2020 training year was provided by trainers not directly employed by the project in one out of five applicable records reviewed.
Employee #1 was hired as a project director on September 15, 2018. The personnel record documented the required 12 hours of training; however, all 12 hours documented were provided by individuals employed within the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will begin training by immediately review the training hours required with all employees of this site and training and review will be ongoing. Facility Director will immediately review the training hours required with all employees of this site with special consideration of the hours outside of the educational hours that are provided by this facility. Facility director trains all staff on obtaining more than half the hours outside the facilities continuing educational hours. Obtaining continuing educational hours and Documentation of those hours will be reviewed on 6/2/21 by the facility director in an all staff meeting. The facility director plans to address, review quarterly with the staff the annual educational plans with special consideration with outside facilities continuing educational hours in addition to the annual plan. |
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.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training during the facility's January 1, 2020 through December 31, 2020 training year in one of three applicable records reviewed.
Employee #4 was hired as a counselor on November 21, 2019. The personnel record documented 21 hours of training.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will immediately review the training hours required with all employees of this site with special consideration of the hours outside of the educational hours that are provided by this facility. Employee # 4 will meet with facility director on 4/26/21 to review their hours and identify how to obtain hours of training and a plan moving forward. The facility director plans to meet quarterly with the entire staff to review educational hour requirements.The Facility Director will begin training by immediately review the training hours required with all employees of this site and training and review will be ongoing. Facility Director will immediately review the training hours required with all employees of this site with special consideration of the hours outside of the educational hours that are provided by this facility. Facility director trains all staff on obtaining more than half the hours outside the facilities continuing educational hours. Obtaining continuing educational hours and Documentation of those hours will be reviewed on 6/2/21 by the facility director in an all staff meeting. The facility director plans to address, review quarterly with the staff the annual educational plans with special consideration with outside facilities continuing educational hours in addition to the annual plan. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the January 2020 through March 2021 fire drill log, the facility failed to conduct unannounced monthly fire drills for the months of November and December of 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has submitted a "special exemption request letter" to the state as there was limited access to the building at that time. The facility director plans to review monthly fire drill logs with the staff as per our policy and procedure. (Letter sent on 4/19/21)
The Facility Director will meet monthly with this staff to review fire drill safety and conduct monthly unannounced fire drills and document accordingly resuming on 4/22/21.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility ' s January 2020 through March 2021 fire drill log, the facility failed to set off the fire alarm or a smoke detector during each monthly fire drill conducted.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director immediately submitted a special request letter to the state as we are requesting that an ETHOS staff member initiates a fire drill as the smoke detector system is wired into the building and would directly impact other tenants in the building.(Letter sent on 4/19/21). The facility director plans to review monthly fire drill logs with the staff as per our policy and procedure.If the letter is rejected the facility director plans to resubmit and request a review. If the 2nd letter is rejected than the facility director will reach out to the building and review options to facilitate a random fire drill in building that does not effect other tenants.
The Facility Director will meet monthly with this staff to review fire drill safety and conduct monthly unannounced fire drills and document accordingly resuming on 4/22/21.
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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
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the record in one of seven client records reviewed.
Client #5 was admitted on September 25, 2020 and was discharged November 27, 2020. There was documentation of a disclosure to the funding source on January 21, 2021. However, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will conduct specific training on importance of completion of written signed completed consent from client for the disclosure of information / 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) and critical nature of obtaining all releases singed on date admission or initial evaluation.
The facility director plans on reviewing critical nature taking time to be correct on date of signature to be in compliance with admission date or evaluation date of service.The Facility Director will randomly review charts seeing if completing all aspects of release are in compliance specifically looking at dates of services and witness signatures. All staff training scheduled for 5/26/21 that The Facility Director will conduct. On 4/22/21 the Facility director will meet with all staff related to client #5 and to review and contact clients to review release of information.
facility director will follow up on Client # 5 and review with all staff involved with failure of completely filling out signed releases of information. The Facility director plans on 5/26/21 an all staff continuing education on the importance of complete and thorough review of clients disclosure of information and their execution to state standards and following our policy and procedure. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in the client's individual treatment and rehabilitation plan in four of seven client records reviewed.
Client #2 was admitted on November 11, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed on November 20, 2020 and included the treatment type; however, the plan did not include the frequency of the treatment and rehabilitation services the client was to receive.
Client #4 was admitted on June 22, 2020 and was discharged on October 16, 2020. The comprehensive treatment plan was completed on June 29, 2020 and included the treatment type; however, the plan did not include the frequency of the treatment and rehabilitation services the client was to receive.
Client #5 was admitted on September 25, 2020 and was discharged on November 27, 2020. The comprehensive treatment plan was completed on September 25, 2020 and included the treatment type; however, the plan did not include the frequency of the treatment and rehabilitation services the client was to receive.
Client #7 was admitted on July 13, 2020 and was discharged on January 27, 2021. The comprehensive treatment plan was completed on July 13, 2020 and included the treatment type; however, the plan did not include the frequency of the treatment and rehabilitation services the client was to receive.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will begin training immediately and training will be ongoing. Clinical Staff will attend a documentation training on 5/5/21 - the documentation of initial treatment plans. All sections of the treatment plan will be covered and reviewed especially that the counselor document type and frequency of services rendered. All staff will document that they understand the intent of this regulation.
On 4/23/21 the facility director will meet with employee directly working with client # 2 and review and document the treatment plan to include the frequency of the treatment and rehabilitation services the client was receiving and to be received in a treatment plan update/
The Facility Director will conduct monthly, random chart audits to ensure that this standard is met on all client records especially with document the type and frequency of treatment and rehabilitation services in the client's individual treatment and rehabilitation plan. |