INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 24, 2021 through March 25, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the June 2020 through March 2021 fire drill log, the facility failed to conduct unannounced monthly fire drills for the months of September, October, November and December of 2020.
These findings were reviewed with facility staff during the licensing process.
|
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 4/21/21. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all personnel, upon employment, are trained to perform assigned tasks during emergencies in one of three personnel records reviewed.
Employee #1 was hired as the Project/Facility Director when the facility opened on June 18, 2020. The emergency preparedness training was not completed as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director has set up a meeting on 4/20/21 to review all emergency procedures with all the staff including Employee # 1. Employee # 1 will comply with all initial preparedness training on 4/20/21. The facility director plans to review monthly fire drill logs with the staff as per our policy and procedure. |
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.
|
Observations
Based on a review of the June 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.
|
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.
IF the letter is not accepted, the facility director plans on clarifying letter , follow up letter to send to state to review that the fire alarm will be a hand held smoke detector. The Facility director plans on meeting with the staff monthly to review fire safety protocols and conduct random fire drills with a smoke detector. |
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.
|
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 three of seven client records reviewed.
Client #1 was admitted on September 28, 2020 and was active at the time of inspection. There was documentation of a disclosure to an employee assistance program on October 22, 2020. However, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client #2 was admitted on November 16, 2020 and was active at the time of inspection. There was documentation of disclosures to the funding source on January 26, 2021 and February 22, 2021. However, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #3 was admitted on November 19, 2020 and was active at the time of inspection. There was documentation of a disclosure to a third-party employee assistance program on December 19, 2020. However, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will conduct specific training on importance of completion of written signed releases of information specifically on it's importance of timely and completely. The staff will all participate on a training on 5/26/21 on documentation of funding sources, EAP's and any and all documentation of disclosure should all be signed at point of entry into program. The critical importance of fully indicating specific information to be disclosed (check all areas which apply) and purpose for releasing information (check all areas which apply) on 5/26/21. The Facility Director will randomly review charts seeing if completing all aspects of release are in compliance. All staff training scheduled for 5/26/21 that The Facility Director will conduct. On 4/21/21 the facility director will review will all staff involved with Client # 1. client # 2 and client # 3 to review ROI. Clients #1 2 and 3 will be contacted by the facility director and an ROI will be sent out to each client to be reviewed and signed by clients. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
|
Observations
Based on a review of client records, the facility failed to document a dated signature of the witness on release of information forms in two of seven client records reviewed.
Client #5 was admitted on October 22, 2020 and discharged on January 22, 2021. A release of information form to an emergency contact was signed and dated by the client on October 13, 2020. The witness signed the document but did not include the date of the signature. Additionally, a release of information form to the funding source was signed and dated by the client on October 13, 2020. The witness signed the document but did not include the date of the signature.
Client #6 was admitted on October 20, 2020 and discharged on December 30, 2020. A release of information form to an emergency contact was signed and dated by the client on October 25, 2020. The dated signature of the witness was completed on October 19, 2020, which was six days prior to the client's signature.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will conduct specific training on importance of completion of written signed 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) on 5/26/21.
The facility director plans on reviewing critical nature of witness signature and 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 4/20/21 the Facility director will meet with all staff related to client #6 and client # 5 to review and contact clients to review release of information. |
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.
|
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 three of seven client records reviewed.
Client #1 was admitted on September 28, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed on October 5, 2020; however, the plan did not include the type and frequency of the treatment and rehabilitation services the client was to receive.
Client #2 was admitted on November 16, 2020 and was active at the time of inspection. The comprehensive treatment plan was completed on November 23, 2020; however, the plan did not include the type and frequency of treatment and rehabilitation services the client was to receive.
Client #7 was admitted on September 7, 2020 and was discharged on January 25, 2021. The comprehensive treatment plan was completed on September 15, 2020; however, the plan did not include the type and frequency of treatment and rehabilitation services the client was to receive.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will begin training immediately and training will be ongoing. Clinical Staff will attend a documentation training on 4/20/21 - the documentation of initial treatment plans & treatment plan updates. All sections of the initial treatment plan will be covered and reviewed especially that the counselor document type and frequency of services rendered. The initial treatment plan as well treatment plan updates should include counselor document type and frequency of services rendered. All staff will document that they understand the intent of this regulation.
The Facility Director will conduct monthly, random chart audits to ensure that treatment plan and documentation of counselor document type and frequency of services rendered standard is met on all client records.
|
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.
|
Observations
Based on a review of client records, the facility failed to provide treatment plan updates within the regulatory timeframe in three of seven client records reviewed.
Client #2 was admitted on November 16, 2020 and was active at the time of inspection. A treatment plan update was completed on January 18, 2021 and the next update was due no later than March 18, 2021. However, the update was not completed as of date of inspection.
Client #6 was admitted on October 20, 2020 and discharged on December 30, 2020. The comprehensive treatment plan was completed on October 28, 2020 and the first update was due no later than December 28, 2020. However, the update was not completed prior to discharge.
Client #7 was admitted on September 7, 2020 and was discharged on January 25, 2021. A treatment plan update was completed on November 10, 2020 and the next update was due no later than January 10, 2021. However, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will begin training on 4/20/21 immediately and training will be ongoing. Clinical Staff will attend a documentation training on the timeliness of treatment plan and treatment plan updates on 05/05/21. All sections of the treatment plan update will be covered and reviewed, including timeliness, goals, and type and frequency requirements. All staff will document that they understand the intent of this regulation. On 5/5/21 The facility director will review client #2, #6 ad # 7 with clinical team to review their treatment plan updates in charts and educate on importance of treatment plan updates in clinical chart.
The Facility Director will conduct monthly, random chart audits to ensure that this standard is met on all client records. |