INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 19, 2022, 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 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of four personnel files, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in two records reviewed.
Employee #3 was hired as a counselor on November 1, 2021 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until January 5, 2022.
Employee #4 was hired as a counselor on November 1, 2021 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until January 5, 2022.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director reviewed with all staff instructions on how to use the Fire extinguishers in a staff meeting on 10/2/22. All staff signed off knowing how to utilize fire extinguisher as well fire exit plans were fully reviewed. On that same date the Facility Director reviewed with HR and leadership on the onboarding process for hiring new staff. The onboarding process indicates that a new hire will complete fire safety prior to their start. The Facility Director will check all new hires in system to ensure this doesn't happen again. |
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 fire drill logs from January 2022 through August 2022, the facility failed to ensure that a fire alarm or smoke detector was set off during any drill.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director met with the building manager, owner to have special clearance to set off fire detectors and test smoke detectors in building during fire-drills for the location. The Facility Director will conduct a surprised fire drill for staff and clients un-announced utilizing the smoke detectors alarms will be used. The facility director will document the alarm and results of the fire drill in the updated fire drill log. |
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 seven records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in five records reviewed.
Client #1 was admitted on November 12, 2021 and was discharged on January 23, 2022. The client did not sign a consent to release information form to the funding source until December 6, 2021; however, the record contained evidence of billing between the date of admission and the date the release was signed.
Client #2 was admitted on December 28, 2021 and was discharged on April 21, 2022. The client did not sign a consent to release information form to the funding source until January 18, 2022; however, the record contained evidence of billing between the date of admission and the date the release was signed.
Client #3 was admitted on February 22, 2022 and was discharged on May 26, 2022. The client did not sign a consent to release information form to the funding source until March 24, 2022; however, the record contained evidence of billing between the date of admission and the date the release was signed.
Client #4 was admitted on March 16, 2022 and was discharged on July 23, 2022. The client did not sign a consent to release information form to the funding source until March 29, 2022; however, the record contained evidence of billing between the date of admission and the date the release was signed.
Client #7 was admitted on January 11, 2022 and was active at the time of the inspection. The client did not sign a consent to release information form to the funding source until February 8, 2022; however, the record contained evidence of billing between the date of admission and the date the release was signed.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director conducted a specific training on 10/10/22 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 10/10/22 especially around funding sources and the timely nature of signing prior to the clients admission to program. The facility director plans on reviewing critical nature of 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. On 10/10/21 the Facility director meet with all staff related to client #1, # 4 and client # 7 to review and contact clients to review release of information to funding sources. The clinicians attempted to reach out to Client #1, #4 and #7 to review on 10/10/22. The Facility Director will follow up to ensure compliance is ongoing met. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on a review of seven client records, the facility failed to obtain consent to treatment during the intake procedures in four records reviewed.
Client #1 was admitted on November 12, 2021 and was discharged on January 23, 2022.
Client #2 was admitted on December 28, 2021 and was discharged on April 21, 2022.
Client #3 was admitted on February 22, 2022 and was discharged on May 26, 2022.
Client #7 was admitted on January 11, 2022 and was active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director conducted a specific training on importance of completion of written signed releases of information specifically obtaining timely signature of consent to participate in treatment on Monday 10/03/22. The facility director plans on reviewing critical nature of signing consent to participate in treatment prior to their entering treatment 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 this are in compliance specifically looking at consent to participate in treatment. All staff attended training scheduled on 10/03/22. that The Facility Director conducted. On 10/4/22 the Facility director will meet with all staff related to client #1, #2,# 3 and # 7 to review missed signatures. The Facility director reviewed with client # 7 the consent and mi-timed signature was documented in their chart. |
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 seven client records, the project failed to develop an individual treatment and rehabilitation plan to include written documentation of type and frequency of treatment and rehabilitation services in three records reviewed.
Client #1 was admitted on November 12, 2021 and was discharged on January 23, 2022. A treatment and rehabilitation plan completed on December 1, 2021 did not include type or frequency of treatment and rehabilitation services.
Client #3 was admitted on February 22, 2022 and was discharged on May 26, 2022. A treatment and rehabilitation plan completed on March 21, 2022 did not include type or frequency of treatment and rehabilitation services.
Client #5 was admitted on April 5, 2022 and was active at the time of the inspection. A treatment and rehabilitation plan completed on April 7, 2022 did not include type or frequency of treatment and rehabilitation services.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The Facility Director will begin training on 10/03/22 immediately and training will be ongoing. Clinical Staff will attend a documentation training on the importance of type and frequency to be documented in the initial treatment plan on 10/3/22. 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 10/4/22 The facility director reached out to client #3, and # 5 with clinical team to review their prior treatment plan and educate on importance of treatment plan in clinical setting.
The Facility Director will conduct monthly, random chart audits to ensure that this standard is met on all client records by specifically checking the type, frequency of services documented in initial treatment plan. |
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 seven client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of six applicable records reviewed.
Client #5 was admitted on April 5, 2022 and was active at the time of the inspection. A treatment plan update was completed on April 7, 2022 and another treatment plan update was due to be completed by June 7, 2022; however, the next treatment plan update was not completed until July 4, 2022.
Client #7 was admitted on January 11, 2022 and was active at the time of the inspection. A treatment plan update was completed on June 7, 2022 and another treatment plan update was due to be completed by August 7, 2022; however, no additional treatment plan updates were completed prior to the date of the inspection.
These finding were discussed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will begin training on 9/26/22 immediately and training will be ongoing. Clinical Staff will attend a documentation training on the timeliness of treatment plan and treatment plan updates on 9/26/22. All sections of the treatment plan update will be covered and reviewed, including timeliness, goals, and type and frequency requirements. All staff will documented that they understand the intent of this regulation. On 9/27/22 The facility director reviewed client #5 and #7 with clinical team to review their treatment plan updates in charts and educate on importance of treatment plan updates in clinical chart immediately this week, completed by 10/18/22.
The Facility Director will conduct monthly, random chart audits to ensure that this standard is met on all client records. |