INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 10, 2023, 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) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on July 10, 2023, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company as the tag on the fire extinguisher in the lobby indicated that the most recent inspection and approval occurred in March 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director of Broomall placed a call to building Mgt company of the Broomall location on 7/11/23. The Mgt company contacted the local fire department on 7/12/23 to have the fire extinguisher checked and re-tagged.
The Facility Director has added monthly fire extinguisher tag checks to the Broomall site audit list. The tag will be checked on 8/1/23 to ensure that the work order has been completed.
Monthly fire drills/audits will continue as part the physical plant standards.
The Facility Director of Broomall has the overall responsibility that this does not recur. |
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
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in seven of seven records reviewed.
Each client record reviewed had a release of information form to the "patient's emergency contact; however, each form in every record reviewed did not include the specific name of the person, agency or organization to whom disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has contacted our software company as of 7/19/23 and made changes to the EMR to include signed completed consent from client for the disclosure of information / releases of information specifically to fully indicating specific information - name of person, agency, or organization to whom the disclosure would be made as part of the client portal system. This software glitch was recognized prior to the visit, but was unable to be upgraded at the time of the inspection.
Training on the new EMR system regarding completion of releases will begin on 7/26/23. All staff will be trained on portal responsibilities and manual entry procedures, if needed. The primary counselor will be responsible moving forward for all needed releases.
The Facility Director and/or Clinical Supervisor will randomly review charts seeing if staff is completing all aspects of releases.
Facility director will follow up on all affected charts, review with all staff involved regarding the failure of completing these releases of information in the proper manner. All affected charts will be amended.
The Facility director and/or clinical supervisor will provide ongoing, individual training for staff members who remain in non-compliance as a result of monthly audits. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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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 date, event, or condition upon which the consent will expire in six records reviewed.
Client # 1 was admitted on November 14, 2022 and was discharged on June 30, 2023. The record contained consent to release information forms to another treatment provider and a family member signed by the client on December 1, 2022, that were missing the date, event, or condition upon which the consent will expire.
Client # 2 was admitted on December 12, 2022 and was discharged on April 6, 2023. The record contained consent to release information forms to another treatment provider and a family member signed by the client on December 15, 2022 and December 12, 2022, respectively, that were missing the date, event, or condition upon which the consent will expire.
Client # 4 was admitted on December 29, 2022 and was discharged on February 24, 2023. The record contained consent to release information forms to another treatment provider and a family member signed by the client on December 29, 2022 and December 28, 2022, respectively, that were missing the date, event, or condition upon which the consent will expire.
Client # 5 was admitted on February 27, 2023 and was active at the time of the inspection. The record contained consent to release information forms to another treatment provider and a family member signed by the client on March 14, 2023 and March 3, 2023, respectively, that were missing the date, event, or condition upon which the consent will expire. Additionally, the record contained a consent to release information form to an attorney signed by the client on June 19, 2023, that was missing the date, event, or condition upon which the consent will expire.
Client # 6 was admitted on March 28, 2023 and was active at the time of the inspection. The record contained a consent to release information form to an employer signed by the client on March 28, 2023, that was missing the date, event, or condition upon which the consent will expire.
Client # 7 was admitted on December 9, 2022 and was active at the time of the inspection. The record contained a consent to release information form to a family member signed by the client on December 9, 2022, that was missing the date, event, or condition upon which the consent will expire.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has contacted our software company as of 7/19/23 and made changes to the EMR to include auto-filled end date (or termination date one year from the date the release has been signed) as part of the client portal system. This software glitch was recognized prior to the visit, but was unable to be upgraded at the time of the inspection.
Training on the new EMR feature regarding "termination/end date" of releases will begin on 7/26/23. All staff will be trained on portal responsibilities and manual entry procedures, if needed. The primary counselor will be responsible moving forward for all needed releases.
The Facility Director and/or Clinical Supervisor will randomly review charts each month seeing if staff is completing the section regarding the expiration date of the release.
Facility director will follow up on all affected charts (for clients #1, 2,4,5,6,and 7) review with all counselors involved regarding the failure of completing and reviewing these releases of information in the proper manner. Also, all active charts will be reviewed and consents signed by the client as is appropriate.
The Facility director and/or clinical supervisor will provide ongoing, individual training for staff members who remain in non-compliance as a result of monthly audits. |
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 review and update treatment and rehabilitation plans at least every sixty days in three of six applicable client records reviewed.
Client # 1 was admitted on November 14, 2022 and was discharged on June 30, 2023. A treatment plan update was completed on February 15, 2023, and the next treatment plan update was due no later than April 15, 2023; however, the update was not completed until June 22, 2023.
Client # 6 was admitted on March 28, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 6, 2023, and the first update was due no later than June 6, 2023; however, the update was not completed until July 6, 2023.
Client # 7 was admitted on December 9, 2022 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 2, 2023, and the first update was due no later than March 2, 2023; however, the update was not completed until April 17, 2023. The next treatment plan update was due to be completed by June 17, 2023; however, it was not completed until July 6, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director did address documentation concerns regarding timeliness of the completion of the Treatment Plan Updates with the clinician responsible for charting for client #1, #6 and #7 on 7/20/23. This will be noted in the chart in the form of an incidental note and amended Treatment Plan Update.
Individualized training for these clinicians in this area will occur on 7/26/23 and clinicians will sign off that they understand the intent of the policy.
The Clinical Supervisor of the Broomall office will conduct, random monthly chart audits regarding the Treatment Plan Updates and ensure that these will be completed in a timely fashion. Additional training will be provided monthly by the Clinical Supervisor to ensure that this standard has been met. |
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 every 90 days, per the facility ' s policy, in three of five applicable records reviewed.
Client # 1 was admitted on November 14, 2022 and was discharged on June 30, 2023. The first case consultation was due to be completed by February 14, 2023; however, it was not documented until March 3, 2023.
Client # 5 was admitted on February 27, 2023 and was active at the time of the inspection. The first case consultation was due to be completed by May 27, 2023; however, it was not documented until July 6, 2023.
Client # 7 was admitted on December 9, 2022 and was active at the time of the inspection. The first case consultation was due to be completed by March 9, 2023; however, it was not documented until April 27, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director did address documentation concerns regarding timeliness of the completion of the Case Consults with the clinician responsible for charting for client #1, #5, and #7 on 7/19/23. This will be noted in the chart in the form of an incidental note and included/amended Case Consult.
Individualized training for these clinicians in this area will occur on 7/26/23 and clinicians will sign off that they understand the intent of the standard.
The Clinical Supervisor of the Broomall office will conduct, random monthly chart audits regarding Case Consults and ensure that these will be completed in a timely fashion. Additional training will be provided monthly by the Clinical Supervisor to ensure that this standard has been met. |
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 three applicable records reviewed.
Client # 2 was admitted on December 12, 2022 and was discharged on April 6, 2023. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on January 31, 2023 and was discharged on April 27, 2023. The client record did not contain documentation of follow-up information.
Client # 4 was admitted on December 29, 2022 and was discharged on February 24, 2023. The client 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 Facility Director did address documentation concerns regarding timeliness of the completion of the 7 day follow-up attempt documentation with the clinician responsible for charting for client #2, #3, and #4 on 7/20/23. This will be noted in the chart in the form of an incidental note and amended follow-up attempt.
Individualized training for these clinicians in this area will occur on 7/26/23 and clinicians will sign off that they understand the intent of the policy/standard.
The Clinical Supervisor of the Broomall office will conduct, random monthly chart audits regarding the follow-up information and ensure that these will be completed in a timely fashion.
Additional training will be provided monthly by the Clinical Supervisor to ensure that this standard has been met. |