INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24, 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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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 annually during the facility's January 1, 2024 through December 31, 2024 training year, in one of three applicable personnel records reviewed.
Employee # 3 has been in the position of counselor since May 18, 2020. The personnel record documented only 10 hours of annual training during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to inspection, ETHOS counted staff meetings towards clinician training hours; however, after being informed that those hours did not qualify, it resulted in multiple employees being under the 25 hour requirement. Moving forward, ETHOS will no longer utilize staff meeting hours as training hours. Staff has already been informed of this matter and has been encouraged to obtain as many hours externally as possible.
Additionally, ETHOS has planned monthly internal training hours to cover a variety of training topics (Tuesdays with Tom & Friends) to ensure that employees are still offered internal training hours.
Lastly, ETHOS now has a designed Director of Compliance who will now manage and track all training hours regularly. An audit of training hours will be conducted on a quarterly basis to ensure that employees are aware of their hours and remain on track to meet the training hour requirements. |
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 eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed.
Client # 8 was admitted on November 14, 2024 and was active at the time of the inspection. There was evidence of disclosures to a family member during family counseling sessions on January 8, 2025, December 18, 2024, and December 11, 2024; however, the consent to release information form to the family member signed by the client on November 12, 2024, did not allow for the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Site Director will immediately conduct a specific individual training with the counselor at this location on the purpose and importance of ensuring that the consent to release information includes the disclosure of information. The counselor was also reminded of their responsibility to check for completed & accurate consents before beginning sessions with new clients, including any family sessions, 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. |
709.93(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 four of six applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed every 90 days.
Client # 1 was admitted on July 19, 2024 and was discharged on November 28, 2024. The record did not contain case consultation notes.
Client # 5 was admitted on July 9, 2024 and was active at the time of the inspection. The first case consultation note was due to be documented by October 7, 2024; however, it was not documented until October 15, 2024.
Client # 6 was admitted on September 20, 2024 and was active at the time of the inspection. The first case consultation note was due to be documented by December 19, 2024; however, it was not documented until January 17, 2025.
Client # 7 was admitted on September 3, 2024 and was active at the time of the inspection. The first case consultation note was due to be documented by December 2, 2024; however, it was not documented until January 2, 2025.
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 Case 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 and the facility ' s policy and procedures manual, 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 19, 2024 and was discharged on November 28, 2024. The record did not contain documentation of follow-up information.
Client # 3 was admitted on August 21, 2024 and was discharged on November 11, 2024. The record did not contain documentation of follow-up information.
Client # 4 was admitted on April 16, 2024 and was discharged on June 28, 2024. Follow-up information was to be documented within one week of discharge, however it was not documented until July 24, 2024.
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 the pertinent clinicians on the completion and documentation (via Incidental Note) of follow-up attempts for all discharged clients in a timely manner.
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. |