INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17, 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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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.
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Observations
Based on a review of four personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in one record reviewed.
Employee # 4 was hired as a counselor on August 23, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until September 5, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, ETHOS has made the Director of Compliance responsible for completing all fire safety activities during new hire orientation, which is to be completed prior to being on shift.
The Director of Operations has also implemented a form that alerts all pertinent parties of upcoming hires, to ensure plenty of time to schedule necessary orientation/trainings within the required timeframe.
These activities have also been added to the onboarding checklist to ensure the activities have been completed and within the required timeframe. |
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.
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Observations
Based on a review of four personnel records, the facility failed to ensure that one applicable staff member was trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 4 was hired as a counselor on August 23, 2024 and is current in that position. Employee # 4 began working shifts on August 23, 2024, but was not trained to perform assigned tasks during emergencies until September 5, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, ETHOS has made the Director of Compliance responsible for completing a review of all emergency procedure activities & responsibilities during new hire orientation, which is to be completed prior to being on shift.
The Director of Operations has also implemented a form that alerts all pertinent parties of upcoming hires, to ensure plenty of time to schedule necessary orientation/trainings within the required timeframe.
These activities have also been added to the onboarding checklist to ensure the activities have been completed and within the required timeframe. |
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 seven 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 # 1 was admitted on April 1, 2024 and was discharged on May 27, 2024. There was evidence of disclosures to a family member during family counseling sessions on May 16, 2024, and May 23, 2024; however, the consent to release information form to the family member signed by the client on April 4, 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. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of seven client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project, in one of one applicable record reviewed.
Client # 1 was admitted on April 1, 2024 and was involuntarily discharged on May 27, 2024. The record contained no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Site Director immediately met with the clinician of the chart to review the deficiency. Clinician was instructed on what to do in the event this were to occur again and how to document it in the chart to meet the regulatory requirements.
Due to the fact that this scenario is a rare occurance for ETHOS, Clinical Leadership discussed this situation during the January All-Staff meeting that took place on January 22, 2025 to ensure all clinical staff was notified. This discussion included a refresher on the policy and a reminder of what to do in the event this scenario arises.
Going forward, the Director of Compliance will be responsible for auditing all client charts that are involuntarily discharged/terminated, to ensure that the appropriate actions were taken and documentation in the chart reflects such actions. |
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 document treatment plan updates within the regulatory timeframe in four of five applicable records reviewed.
Client # 3 was admitted on May 15, 2024 and was discharged on December 20, 2024. The individual treatment and rehabilitation plan was completed on May 29, 2024, and the treatment plan update was due no later than July 28, 2024; however, the update was not completed until August 2, 2024. The next treatment plan update was due to be completed by October 1, 2024; however, no treatment plan updates were completed prior to discharge.
Client # 4 was admitted on August 20, 2024 and was discharged on December 19, 2024. The individual treatment and rehabilitation plan was completed on September 4, 2024, and the treatment plan update was due no later than November 3, 2024; however, no treatment plan updates were completed prior to discharge.
Client # 5 was admitted on July 18, 2024 and was active at the time of the inspection. A treatment plan update was completed on September 18, 2024, and the treatment plan update was due no later than November 17, 2024; however, the update was not completed until November 24, 2024.
Client # 7 was admitted on August 8, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 2, 2024, and the treatment plan update was due no later than October 1, 2024; however, no treatment plan update was completed prior to the date of the inspection.
This is a repeat citation from the March 28, 2024 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance met with the Clinical leadership team on 2/10/2025 to determine a plan for ongoing compliance with this regulation.
The Clinical Site Supervisor has met with the clinician for this site to review the citation and reinforce the policy and requirement to complete treatment plan updates every 60 days from the initial treatment plan. Active client charts were reviewed for compliance and any treatment plan updates were completed, when necessary.
Starting immediately, the Director of Compliance will audit all charts for all clinicians specifically for treatment plans and treatment plan updates for the next 30 days to ensure all charts are in compliance. The Director of Compliance will identify any trends in non-compliance with the regulations and meet with the team again to reassess the approach and provide additional, if necessary. In addition to the Training Plan Update audits, the Director of Compliance will complete thorough chart audits for all components on an ongoing basis to ensure continuous compliance.
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 treatment plan updates). 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. |
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 five applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed every 90 days.
Client # 3 was admitted on May 15, 2024 and was discharged on December 20, 2024. The second case consultation note was due to be completed by November 2, 2024; however, no additional case consultation notes were documented prior to discharge.
Client # 4 was admitted on August 20, 2024 and was discharged on December 19, 2024. The record did not contain documentation of case consultation notes.
Client # 6 was admitted on October 10, 2024 and was active at the time of the inspection. The record did not contain documentation of case consultation notes.
Client # 7 was admitted on August 8, 2024 and was active at the time of the inspection. The first case consultation was not documented until December 19, 2024.
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, 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 April 1, 2024 and was discharged on May 27, 2024. The record did not contain documentation of follow-up information.
Client # 3 was admitted on May 15, 2024 and was discharged on December 20, 2024. The record did not contain documentation of follow-up information.
Client # 4 was admitted on August 20, 2024 and was discharged on December 19, 2024. The 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 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. |