INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28, 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 fiscal year ending on December 31, 2021.
This is a repeat citation from the March 14, 2022 and April 7, 2021 annual licensing renewal inspections.
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 one of seven client records reviewed.
Client # 5 was admitted on October 10, 2022 and was discharged on January 17, 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 finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will conduct specific training on importance of completion of written signed completed consent from client for the disclosure of information / releases of information specifically to fully indicating specific information - name of person, agency, or organization to whom the disclosure would be made and critical nature of obtaining all releases singed on date admission or initial evaluation.
The Facility Director will randomly review charts seeing if completing all aspects of releases are in compliance specifically looking at the content named above. All staff training scheduled for 4/26/23 that The Facility Director will conduct. On 4/20/23 the Facility director will meet with all staff related to client #5 to review and contact clients to review release of information. |
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 six of seven client records reviewed.
Client # 1 was admitted on August 26, 2022 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the client on September 19, 2022; however, the form did not include the specific name of the person, agency, or organization to whom the disclosure would be made.
Client # 2 was admitted on October 26, 2022 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the client on October 27, 2022; however, the form did not include the specific name of the person, agency, or organization to whom the disclosure would be made.
Client # 3 was admitted on September 20, 2022 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the client on September 20, 2022; however, the form did not include the specific name of the person, agency, or organization to whom the disclosure would be made.
Client # 4 was admitted on September 21, 2022 and was discharged on February 2, 2023. The release of information form to an emergency contact was signed and dated by the client on September 21, 2022; however, the form did not include the specific name of the person, agency, or organization to whom the disclosure would be made.
Client # 6 was admitted on December 1, 2022 and was discharged on February 20, 2023. The release of information form to an emergency contact was signed and dated by the client on December 1, 2022; however, the form did not include the specific name of the person, agency, or organization to whom the disclosure would be made.
Client # 7 was admitted on December 15, 2022 and was discharged on March 5, 2023. The release of information form to an emergency contact was signed and dated by the witness on December 15, 2022; however, the form did not include the specific name of the person, agency, or organization to whom the disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will conduct specific training on importance of completion of written signed completed consent from client for the disclosure of information / releases of information specifically to fully indicating specific information - name of person, agency, or organization to whom the disclosure would be made and critical nature of obtaining all releases singed on date admission or initial evaluation.
The Facility Director will randomly review charts seeing if completing all aspects of releases are in compliance specifically looking at the content named above. All staff training scheduled for 4/26/23 that The Facility Director will conduct. On 4/20/23 the Facility director will meet with all staff related to client #1, #2, #3, #4, #6 and #7 and to review and contact clients to review release of information.
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. Furthermore, the facility director will conduct random chart audits to ensure compliance with the new intake packet procedure.
able on both documents.
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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 document the dated signature of the client on release of information forms in one of seven client records reviewed.
Client # 7 was admitted on December 15, 2022 and was discharged on March 5, 2023. The release of information forms to the emergency contact and the funding source were signed and dated by the client's parent on December 15, 2022, but the consent forms did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will conduct specific training on importance of completion of written signed completed consent from client for the disclosure of information / releases of information specifically to fully indicating specific information - name of person, agency, or organization to whom the disclosure would be made and critical nature of obtaining all releases singed on date admission or initial evaluation.
The Facility Director will randomly review charts seeing if completing all aspects of releases are in compliance specifically looking at the content named above. All staff training scheduled for 4/26/23 that The Facility Director will conduct. On 4/20/23 the Facility director will meet with all staff related to client #7 and to review and contact clients to review release of information specifically to review policy of client signature and date priority and not guardian or family member.
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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 five of seven client records reviewed.
Client # 1 was admitted on August 26, 2022 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 30, 2022 and the first update was due no later than October 30, 2022; however, the update was not completed until November 20, 2022. Additionally, a treatment plan update was completed on November 20, 2022 and the next update was due no later than January 20, 2023; however, the update was not completed until February 1, 2023.
Client # 3 was admitted on September 20, 2022 and was still active at the time of the inspection. A treatment plan update was completed on November 29, 2022 and the next update was due no later than January 29, 2023; however, the update was not completed until February 20, 2023.
Client # 4 was admitted on September 21, 2022 and was discharged on February 2, 2023. The individual treatment and rehabilitation plan was completed on September 29, 2022 and the first update was due no later than November 29, 2022; however, the update was not completed until December 13, 2022.
Client # 6 was admitted on December 1, 2022 and was discharged on February 20, 2023. The individual treatment and rehabilitation plan was completed on December 8, 2022 and the first update was due no later than February 8, 2023; however, the update was not completed prior to discharge.
Client # 7 was admitted on December 15, 2022 and was discharged on March 5, 2023. The individual treatment and rehabilitation plan was completed on December 27, 2022 and the first update was due no later than February 27, 2023; however, the update was not completed prior to discharge.
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 , # 3 , #4 , #6 # 7 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 Facility Director 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. |
709.17(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 annual financial audit was submitted and approved by the Department for the March 14, 2022 and April 7, 2021 annual licensing inspections. Failing to complete an annual financial audit was again found to be a deficiency in the March 28, 2023 licensing 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.
The Leadership team of ETHOS, specifically the facility Director and COO 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 the financial review.
In the interim, to be transparent 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 that 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. If/when this request exception comes thru we will immediately submit to reviewer. 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. |