INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21, 2023 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. At the time of the inspection, there was no annual financial audit completed for the facility's fiscal year ending on December 31, 2021.
This is a repeat citation from the March 9, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ETHOS is in the process of completing a review of Financial Statements by a Certified Public Accounting firm for fiscal year of 2022. This firm is now contracted to complete the same review every year for ETHOS, with the next review for the fiscal year ending 2023 to begin in January of 2024 and to be completed no later than May 30 2024.
ETHOS also has available tax returns, staffing records, payroll records, agreements for third-party reimbursement, and related documents in relation to Fiscal Year 2021 to show good standing throughout the year.
Finally, ETHOS COO has requested an exception to Title 28, Chapter § 709.25 Fiscal Management requirement of the Standards for Licensure of Freestanding Treatment Facilities for the fiscal years ended December 31, 2021 due to the time and financial burden of completing these reviews by the end of the licensing period. In the event the request is denied, ETHOS COO will engage the same CPA firm to prepare a review of financial statements for the fiscal year 2021 to be completed by October 31, 2023. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed.
Client # 2 was admitted on August 30, 2022 and was still active at the time of the inspection. There was evidence of disclosures to family members during a family counseling session on October 25, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client # 7 was admitted on September 20, 2022 and was discharged on January 20, 2023. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This is a repeat citation from the March 25, 2021 and March 9, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director with assistance of the Chief Operations Officer and Clinical Supervisor of Philadelphia have begun the conversion to our newest version of EMR as of 4/20/23.
With the implementation of the newest version of our EMR; the Client Intake Packet, including all required releases, will now be managed through the Client Portal. This will ensure that all necessary releases and information are gathered, signed, and securely stored in the EMR on client evaluation. Therapists are trained to ensure the entire packet, including releases, is completed prior to starting any treatment. All therapists will be trained by May 20, 2023.
In the interim period, the releases for client #2 and client #7 will be corrected and amended in the EMR. This is the responsibility of the Philadelphia Counselors and noted in the EMR with and incidental note.
Furthermore, the facility director will conduct random chart audits specifically to a review completed documented release of informations all in chart to ensure compliance with the new intake packet procedure is being followed and amendments have been made.
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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 of the person, agency, or organization to whom disclosure is made on consent to release information forms in seven of seven client records reviewed.
Each client record reviewed had a release of information form to the "patient's emergency contact"; however, each form in every record reviewed did not include the specific name of the person, agency or organization to whom disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director with assistance from the Chief Operations Officer and Clinical Supervisor of Philadelphia have begun the process of training around releases containing "Emergency Contact Information" as of 4/20/23.
With the implementation of the newest version of our EMR -the Client Intake Packet, including all required releases, will now be managed through the Client Portal. The Emergency Contact information gathered will be automatically entered into the release of information page to be unique to the client. This will ensure that all necessary releases and information are gathered, signed, and securely stored in the EMR on client evaluation. Therapists are trained to ensure the entire packet, including emergency contact releases, is completed prior to starting any treatment. All therapists will be trained by May 20, 2023 on the new system/procedures.
In the interim period, Philadelphia Counselors will amend the releases of charts for client #1, 2, 3, 4, 5, 6, and 7. Also this will be noted in the EMR with an incidental note.
Furthermore, the facility director and clinical supervisor of Philadelphia will conduct random chart audits to ensure compliance with the new intake packet procedure and that the amended notations have been completed.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation of the client within the timeframe documented in the facility policy in four of seven applicable client records reviewed.
The facility policy and procedure manual stated that the psychosocial evaluation is to be completed within three days of the biopsychosocial histories.
Client # 2 was admitted on August 30, 2022 and was still active at the time of the inspection. The biopsychosocial history was completed on September 5, 2022 and the psychosocial evaluation was due to be completed no later than September 8, 2022; however, the evaluation was not completed until September 13, 2022.
Client # 4 was admitted on November 7, 2022 and was discharged on March 14, 2023. The biopsychosocial history was completed on November 8, 2022 and the psychosocial evaluation was due to be completed no later than November 11, 2022; however, the evaluation was not completed until November 17, 2022.
Client # 6 was admitted on September 29, 2022 and was discharged on December 18, 2022. The biopsychosocial history was completed on September 28, 2022 and the psychosocial evaluation was due to be completed no later than October 1, 2022; however, the evaluation was not completed until October 17, 2022.
Client # 7 was admitted on September 20, 2022 and was discharged on January 20, 2023. The biopsychosocial history was completed on September 20, 2022 and the psychosocial evaluation was due to be completed no later than September 23, 2022; however, the evaluation was not completed until October 25, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will address documentation concerns regarding timeliness of the completion of the Biopsychosocial Summaries with the clinician responsible for charting for client #2, #4, #6, and #7 on 4/20/23. This will be noted in the chart in the form of an incidental note.
Individualized training for these clinicians in this area will occur on 4/26/23 and clinicians will sign off that they understand the intent of the policy.
The Clinical Supervisor of Philadelphia office will conduct, random monthly chart audits regarding the Biopsychosocial Summaries and ensure that these will be completed in a timely fashion. Additional training will be provided monthly by the Clinical Supervisor to ensure that this standard has been met. |
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.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of seven client records reviewed.
Client # 1 was admitted on October 31, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 15, 2022; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on October 6, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 11, 2022; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on November 7, 2022 and was discharged on March 14, 2023. The individual treatment and rehabilitation plan was completed on December 2, 2022; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
Client # 7 was admitted on September 20, 2022 and was discharged on January 20, 2023. The individual treatment and rehabilitation plan was completed on November 1, 2022; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
This is a repeat citation from the March 25, 2021 and March 9, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will address documentation concerns regarding timeliness of the completion of the Individual Treatment Plan - specifically around type and frequency of services with the clinician responsible for charting for client #1, #3, #4, and #7 on 4/20/23. This will be noted in the chart in the form of an incidental note and amended Treatment Plan.
The New EMR system will introduce a new Treatment Plan form which has a section specifically highlighting Type and Frequency of services rendered. This new version will be completed by 5/20/23 and progress will be monitored weekly by the Facility Director during implementation.
Individualized training for the clinicians impacted in this area will occur on 4/26/23 and clinicians will sign off that they understand the intent of the policy.
The Clinical Supervisor of Philadelphia office will conduct, random monthly chart audits regarding the Individual Treatment Plans and ensure that these will be completed in an accurate, timely fashion. Additional training will be provided monthly by the Clinical Supervisor to ensure that this standard has been met prior to 5/20/23. |
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 review and update treatment and rehabilitation plans at least every sixty days in two of five applicable client records reviewed.
Client # 1 was admitted on October 31, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on December 15, 2022 and the first update was due no later than February 15, 2023; however, the update was not completed until March 1, 2023.
Client # 2 was admitted on August 30, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 27, 2022 and the first update was due no later than November 27, 2022; however, the update was not completed until March 1, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will address documentation concerns regarding timeliness of the completion of the Treatment Plan Updates with the clinician responsible for charting for client #1 and #2 on 4/20/23. This will be noted in the chart in the form of an incidental note and amended Treatment Plan Update.
Individualized training for these clinicians in this area will occur on 4/26/23 and clinicians will sign off that they understand the intent of the policy.
The Clinical Supervisor of Philadelphia office will conduct, random monthly chart audits regarding the Treatment Plan Updates and ensure that these will be completed in a timely fashion. Additional training will be provided monthly by the Clinical Supervisor to ensure that this standard has been met. |
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, the facility failed to maintain a complete client record, which is to include case consultation notes, in two of five applicable client records reviewed.
Client # 4 was admitted on November 7, 2022 and was discharged on March 14, 2023 There was no case consultation notes documented in the record at the time of the inspection.
Client # 7 was admitted on September 20, 2022 and was discharged on January 23, 2023. There was no case consultation notes documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will address documentation concerns regarding timeliness of the completion of the Case Consultations with the clinician responsible for charting for client #4 and #7 on 4/20/23. This will be noted in the chart in the form of an incidental note and an amended Clinical Consult completed.
Individualized training for these clinicians in this area will occur on 4/26/23 and clinicians will sign off that they understand the intent of the policy. The Clinical Supervisor of Philadelphia will complete this training.
The Clinical Supervisor of Philadelphia office will conduct, random monthly chart audits regarding the Case Consultations and ensure that these will be completed in a timely fashion. Additional training will be provided monthly by the Clinical Supervisor to ensure that this standard has been met by 5/20/23. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to complete an informed and voluntary consent to release information form prior to the disclosure of information was submitted and approved by the Department for the March 9, 2022 and March 25, 2021 annual licensing inspections. Failing to complete an informed and voluntary consent to release information form prior to the disclosure of information was again found to be a deficiency in the March 21, 2023 licensing inspection.
A plan of correction for failing to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan was submitted and approved by the Department for the March 9, 2022 and March 25, 2021 annual licensing inspections. Failing to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan was again found to be a deficiency in the March 21, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director with assistance of the Chief Operations Officer have begun the process of final conversion to our new EMR as of 4/20/23.
With the implementation of the newest version of our EMR Treatment Type and Frequency will be automatically carried over from the Initial Evaluation to the Initial Treatment Plan. This will ensure all necessary information is available in the Treatment Plans and Treatment Plan Update. The facility director and Clinical Supervisor of Philadelphia will conduct random chart audits to ensure compliance of completion of the initial treatment plan in the initial evaluation and the comprehensive treatment plan coordinated.
With the implementation of the newest version of our EMR the Client Intake Packet, including all required releases, will now be managed through the Client Clinical Portal. This will ensure that all necessary releases and information are gathered, signed, and securely stored in the EMR on client evaluation. Therapists are trained to ensure the entire packet, including emergency releases is completed prior to starting any treatment. All therapists will be trained by May 20, 2023. Progress on training will be documented weekly by Facility Director of Philadelphia. The new EMR will also automatically flag incomplete releases of information to immediately address. The new EMR will automatically fill in full names and completed forms.
In the interim period, all affected documents will be manually amended and corrected. It is the responsibility of the Philadelphia Counselors to complete this task on all affected EMR from recent inspection.
Furthermore, the facility director and Clinical Supervisor of Philadelphia will conduct random chart audits to ensure compliance with the new intake packet procedure and viability on both documents.
The Leadership team of ETHOS, specifically the facility Director, the Philadelphia clinical director and two of the site's therapists and representative from the EMR will meet quarterly to monitor the completion of the plan of correction. This Administrative review of the plan of correction will be adopted as a quarterly review to show that this corrective plan will be followed, completed as well will be continued to be followed to be in full satisfaction to the state requirements of this plan of corrections. This administrative review in person quarterly to review the plan of corrections to confirm the Plan of corrections of release of information successful full completion of documentation in treatment planning as well in type and frequency. On a quarterly basis the leadership team with the therapists will check the plan of corrections on a quarterly basis that the emergency releases and all intake packets are up to date and fully complete.
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