INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26, 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) 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 an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #6 was admitted on October 23, 2023 and was discharged February 2, 2024. There was documentation of billing to the funding source during the client's treatment episode; however, there was no consent to release information form in the record prior to the disclosures of information.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will immediately conduct a specific individual training with the Counselor of client #6 on importance of timely completion of written consent form for the disclosure of information / releases of information - to document the specific funding source of the client in the ROI.
This standard will be reinforced at a site specific staff training on the proper way to complete a release of information which will occur on 4/30/24 at 12:30pm. The Clinical Supervisor will conduct the training.
The Clinical Supervisor of this location will randomly review charts on a monthly basis to ensure that all funding releases are completed entirely & properly. If a counselor at this location continues to not meet the standard, then additional individualized trainings will be arranged & instruction repeated on proper way to complete/date a release of information.
Audits will continue monthly until the standard is met by all staff. |
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 the person, agency, or organization to whom disclosure is made on consent to release information forms in four of seven client records reviewed.
Client #1 was admitted September 18, 2023 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on September 18, 2023; however, the release form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
Client #3 was admitted October 19, 2023 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on October 19, 2023; however, the release form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
Client #4 was admitted August 21, 2023 and was discharged February 12, 2024. A release of information form to the funding source was signed and dated by the client on August 21, 2023; however, the release form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
Client #7 was admitted August 31, 2023 and was discharged February 1, 2023. A release of information form to the funding source was signed and dated by the client on August 31, 2023; however, the release form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
This is a repeat citation from the July 10, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will immediately conduct a specific individual training with the Counselors of client #1, #3, #4, and #7 on importance of timely completion of written consent form for the disclosure of information / releases of information - to document the specific name of a person, agency, or organization in the ROI.
The assigned counselor(s) will meet with client #1 & #3 about this issue and note this in an incidental note with an amended release noted since these clients are still active.
This standard will be reinforced at a site specific staff training on the proper way to complete a release of information which will occur on 4/30/24 at 12:30pm. The Clinical Supervisor will conduct the training.
The Clinical Supervisor of this location will randomly review charts on a monthly basis to ensure that all releases are completed entirely & properly. If a counselor at the this location continues to not meet the standard, then additional individualized trainings will be arranged & instruction repeated on proper way to date a release of information.
Audits will continue monthly until the standard is met by all staff. |
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 client records, the facility failed to ensure the signature of the client on consent to release information forms was dated in one of seven client records reviewed.
Client #2 was admitted June 16, 2023 and was active at the time of inspection. The release of information form to the funding source was signed by the client; however, there was no date of when the client signed included on the release form.
This is a repeat citation from the July 10, 2023 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will immediately conduct a specific individual training with the Counselor of client #2 on importance of timely completion of written consent form for the disclosure of information / releases of information - specifically to be aware and vigilant about the date a released is signed. The counselor will meet with client #2 about the date issue and note this in an incidental note with an amended release noted.
This standard will be reinforced at a site specific staff training on the proper way to complete a release of information which will occur on 4/30/24 at 12:30pm. The Clinical Supervisor will conduct the training.
The Clinical Supervisor of this location will randomly review charts on a monthly basis to ensure that all releases are dated properly. If a counselor at the this location continues to not meet the standard, then additional individualized trainings will be arranged & instruction repeated on proper way to date a release of information.
Audits will continue monthly until the standard is met by all staff. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent was offered to the client in one of seven client records reviewed.
Client #2 was admitted June 16, 2023 and was active at the time of inspection. Release of information forms to the funding source and the emergency contact were signed and dated by the client on June 16, 2023; however, there was no documentation that a copy of both release forms were offered to the client.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will immediately conduct a specific individual training with the Counselor of client #2 on importance of completion of written consent form for the disclosure of information / releases of information - specifically to document that the client either accepted or rejected a copy of the ROI.
The counselor will meet with client #2 and offer a copy of the release since this client is still "active". This will be documented in the EMR in the form of an incidental note.
This standard will be reinforced at a site specific staff training on the proper way to complete a release of information which will occur on 4/30/24 at 12:30pm. The Clinical Supervisor will conduct the training.
The Clinical Supervisor of this location will randomly review charts on a monthly basis to ensure that all releases are completed properly and that there is proof a copy was offered to the client. If a counselor at the this location continues to not meet the standard, then additional individualized trainings will be arranged & instruction repeated on proper way to document that a client was offered a copy of a release of information.
Audits will continue monthly until the standard is met by all staff. |