INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 12, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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709.28 (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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in two of seven patient records reviewed.
Client #4 was admitted on December 13, 2018 and was discharged on April 29, 2019. The release of information form to the funding source stated that the client had "refused to sign" on December 13, 2018. There was documentation that the facility had contacted the funding source during the client's treatment episode without a proper release of information form documented in the record prior to the disclosure.
Client #6 was admitted on December 2, 2018 and was discharged on February 26, 2019. The release of information form to the funding source stated that the client had "refused to sign" on December 3, 2018. There was documentation that the facility had contacted the funding source during the client's treatment episode without a proper release of information form documented in the record prior to the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will begin training immediately and training will be ongoing. The Facility Director will review the Ethos Consent to Release information form in staff meeting starting 6/21/19. All Plymouth Meeting location staff will attend a formal training on site on 7/17/19 where all sections of the release will be reviewed and charts from previous audit on 6/12/19 will be reviewed. Counselors will be required to review release and implement procedures for release involving third party payors/funding sources and confidentiality (255.5).
All staff will sign off that they understand the standards.
The Facility Director will conduct random, monthly audits to ensure that this standard is being met on all records. |
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
The facility failed to properly document that the individual's comprehensive treatment and plan was developed with the client in two of seven client records reviewed. Additionally, the facility failed to properly document, on the comprehensive treatment plan, which type(s) of services the client was to receive during treatment and the frequency of those services in all seven client records reviewed.
Client #1 was admitted on February 14, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was signed and dated April 4, 2019 by the counselor; however, there was no client signature or written documentation that the plan was developed with the client's input. Additionally, there was no type of service and frequency of service documented on the treatment plan.
Client #2 was admitted on November 21, 2018 and was still active at the time of the inspection. There was no type of service and frequency of service documented on the treatment plan, which was dated December 10, 2018.
Client #3 was admitted on January 31, 2019 and was still active at the time of the inspection. There was no type of service and frequency of service documented on the treatment plan, which was dated February 14, 2019.
Client #4 was admitted on December 13, 2018 and was discharged on April 29, 2019. The comprehensive treatment plan was signed and dated December 20, 2018 by the counselor; however, there was no client signature or written documentation that the plan was developed with the client's input. Additionally, there was no type of service and frequency of service documented on the treatment plan.
Client #5 was admitted on September 4, 2018 and was discharged on February 26, 2019. There was no type of service and frequency of service documented on the treatment plan, which was dated September 14, 2018.
Client #6 was admitted on December 2, 2018 and was discharged on February 26, 2019. There was no type of service and frequency of service documented on the treatment plan, which was dated December 10, 2018.
Client #7 was admitted on October 25, 2018 and was discharged on April 4, 2019. There was no type of service and frequency of service documented on the treatment plan, which was dated November 27, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will begin training immediately and training will be ongoing. The Facility Director and Counselors of Plymouth meeting location will attend a mandatory training on 7/17/19. Until the training occurs information regarding where documentation of Treatment Plans will be reviewed, including: documentation on each record which indicates that the client was involved in development of the treatment plan (note or incidental note in medical record) and that the types and frequency of services is clearly stated in the treatment plan.
This deficiency review will occur in the weekly staff meeting at Plymouth Meeting. The counselor for client #1,2,3,4,5,6, and 7 will reach out to the active clients and document that the client is aware of amended information and has given appropriate input. If the chart is closed, the counselor will place a memo in client record that specific documentation is missing by 7/18/19.
The Facility Director will conduct random, monthly chart audits to ensure that this standard is being met on all client records. |
709.93(a) 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:
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Observations
The facility failed to provide a complete client record, which is to include case consultation notes and follow up information, in four of seven client records reviewed.
Client #1 was admitted on February 14, 2019 and was still active at the time of the inspection. The client record failed to document case consultation notes which are to be completed at least every 90 days, according to the facility's policy and procedure manual.
Client #4 was admitted on December 13, 2018 and was discharged on April 29, 2019. The client record failed to document any post-discharge follow up information which is to be completed within 60 days of discharge, according to the facility's policy and procedure manual.
Client #5 was admitted on September 4, 2018 and was discharged on February 26, 2019. The client record failed to document case consultation notes which are to be completed at least every 90 days, according to the facility's policy and procedure manual.
Client #6 was admitted on December 2, 2018 and was discharged on February 26, 2019. The client record failed to document any post-discharge follow up information which is to be completed within 60 days of discharge, according to the facility's policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will begin training immediately and training will be ongoing. The Facility Director and Counselors at Plymouth Meeting location will attend a mandatory training on 7/17/19 which will review the standards for documentation of case consults and follow up information.
All staff must attend this training. Counselors will review results of audit and methods to document according to State standards in their weekly staff meeting up until the training occurs. The counselor for clients #1 and #5 will contact all active clients to make them aware of missing documentation and obtain the client's input and place in the medical record by 7/18/19. The followup documentation for closed clients #4 and #6 will include a memo regarding missing followup contact in the medical record by 7/18/19.
The Facility Director will conduct random, monthly chart audits to ensure that the standard is being met on all client records. |