INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 10, 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's January 1, 2024 through December 31, 2024 training year, in two of two applicable personnel records reviewed.
Employee # 3 has been in the position of counselor since September 15, 2018. The personnel record documented only 22.5 hours of annual training during the training year reviewed.
Employee # 4 has been in the position of counselor since December 5, 2022. The personnel record documented only 21.5 hours of annual training during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to inspection, ETHOS counted staff meetings towards clinician training hours; however, afterbeing informed that those hours did not qualify, it resulted in multiple employees being under the 25 hour requirement. Moving forward, ETHOS will no longer utilize staff meeting hours as training hours. Staff has already been informed of this matter and has been enoucraged to obtain as many hours externally as possible.
Additionally, ETHOS has planned monthly internal training hours to cover a variety of training topics (Tuesdays with Tom & Friends) to ensure that employees are still offered internal training hours.
Lastly, ETHOS now has a designed Director of Compliance who will now manage and track all training hours regularly. An audit of training hours will be conducted on a quarterly basis to ensure that employees are aware of their hours and remain on track to meet the training hour requirements. |
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 two records reviewed.
Client # 3 was admitted on June 14, 2024 and was discharged August 5, 2024. The consent to release information form to the funding source was not signed until August 2, 2024; however, there was evidence of billing prior to the client signed consent to release information form.
Client # 6 was admitted on July 9, 2024 and was active at the time of the inspection. There was evidence of disclosures to a family member during a family counseling session on October 22, 2024; however, the consent to release information form allowing the disclosures was not signed by the client until November 11, 2024.
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 counselors at this location on importance of timely completion of written consent form for the disclosure of information / releases of information - specifically to be aware and vigilant about the date a released is signed. The counselor was also reminded of their responsibility to check for completed consents before beginning sessions with new clients, as well as before disclosing any information to any additional parties, which includes the action of checking for signed consent prior to a family session.
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. |
709.91(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 and the facility's policies and procedures, the facility failed to document a psychosocial evaluation in three of seven applicable records reviewed. The facility policy states that new admissions are to have a psychosocial evaluation completed within 17 days of admission.
Client # 1 was admitted on June 26, 2024 and was discharged on September 7, 2024. The psychosocial evaluation was not completed until August 4, 2024.
Client # 3 was admitted on June 14, 2024 and was discharged August 5, 2024. The psychosocial evaluation was not completed until July 28, 2024.
Client # 5 was admitted on August 14, 2024 and was active at the time of the inspection. The psychosocial evaluation was not completed until September 21, 2024.
These finding 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 this specific clinician at this site to review ETHOS policy regarding the completion of a psychosocial evaluation within a clients first 2 weeks of treatment. Clinician was reminded that documentation is considered "completed" based on the date of signature, not the date the document was created. Active client charts were reviewed for compliance and any psychosocial evaluations were completed, when necessary.
The Director of Compliance will be conducting regular, thorough chart audits to ensure timely completion of required documentation, including the BPS. Any trends in non-compliance are to be reported to the appropriate Clinical Site Supervisor for additional training.
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 psychosocial evaluations). 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.
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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 14 days of admission, per the facility policy, in five of seven records reviewed.
Client # 1 was admitted on June 26, 2024 and was discharged on September 7, 2024. The individual treatment and rehabilitation plan was due to be completed by July 10, 2024; however, it was not completed until August 18, 2024.
Client # 3 was admitted on June 14, 2024 and was discharged August 5, 2024. The individual treatment and rehabilitation plan was due to be completed by June 28, 2024; however, it was not completed until August 18, 2024.
Client # 5 was admitted on August 14, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by August 28, 2024; however, it was not completed until November 11, 2024.
Client # 6 was admitted on July 9, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed by July 23, 2024; however, it was not completed until July 27, 2024.
Client # 7 was admitted on September 3, 2024 and discharged on December 30, 2024. The individual treatment and rehabilitation plan was due to be completed by September 17, 2024; however, it was not completed until September 19, 2024.
The findings were reviewed 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 clinicians at this site to review ETHOS policy regarding the completion of an initial treatment plan within 14 days of admission. Clinicians were reminded that documentation is considered "completed" based on the date of signature, not the date the document was created. 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 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. |
709.92(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 # 2 was admitted on March 21, 2024 and was discharged on October 3, 2024. The individual treatment and rehabilitation plan was completed on March 31, 2024, and the treatment plan update was due no later than May 30, 2024; however, the update was not completed until June 2, 2024.
Client # 4 was admitted on May 14, 2024 and was discharged on August 12, 2024. The individual treatment and rehabilitation plan was completed on May 24, 2024, and the treatment plan update was due no later than July 23, 2024; however, no treatment plan updates were completed prior to discharge.
Client # 6 was admitted on July 9, 2024 and was active at the time of the inspection. A treatment plan update was completed on September 27, 2024, and the treatment plan update was due no later than November 26, 2024; however, the update was not completed until November 30, 2024.
Client # 7 was admitted on September 3, 2024 and was discharged December 30, 2024. The individual treatment and rehabilitation plan was completed on September 19, 2024, and the treatment plan update was due no later than November 18, 2024; however, the update was not completed until November 25, 2024.
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 clinicians at 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)(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 policy and procedure manual, and a discussion with the clinical supervisor, 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 six applicable records reviewed. According to facility policy and facility staff, follow-up information is to be completed and documented within seven days of discharge.
Client # 3 was admitted on June 14, 2024 and was discharged August 5, 2024. Follow-up information was not documented in the record until December 15, 2024.
Client # 7 was admitted on September 3, 2024 and was discharged December 30, 2024. Follow-up information was not documented in the record until January 10, 2025.
Client # 8 was admitted on August 28, 2024 and was discharged on November 21, 2024. Follow-up information was not documented in the record until January 2, 2025.
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. |