INITIAL COMMENTS
|
This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on August 22-23, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, ECHO Treatment Center, 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 the inspection:
|
Plan of Correction
|
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.
|
Observations
The facility failed to obtain a complete informed and voluntary consent from the client for the disclosure of information contained in the client record in eight of eight client records reviewed on August 22-23, 2017.
Eight records were reviewed and all documented consents from the clients.
In client records # 1, 2, 3, 4, 5, 6, 7 and 8, the consent for the client's emergency contact did not document the expiration date of the consent and whether the client had been offered a copy of the consent.
Client records # 1, 2, 3, 4, 5, 6, 7 and 8 documented consents that were missing the person/organization to whom the information was to be released.
Client # 1, 2 and 3 documented consents that were missing the specific information to be released.
Client # 4- Information released in a letter to a government agency exceeded parameters of 255.5.
Client # 8- Information released in a letter to an employer exceeded parameters of 255.5.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/25/2017, Clinical Supervisor held a training with all clinical staff on the accurate completion and documentation required for a proper consent which included, the specific information to be released, organization/person to whom the information will be released, and documentation offering the client a copy. The training also included a review of the specific information that can and can not be released to government agencies and employers with consent. The emergency contact consent forms have been updated to include what information can be released to the emergency contact person and the terms of expiration of the consent. Clinical supervisor will conduct random chart reviews on a regular basis to ensure compliance with these confidentiality procedures and to ensure these deficiencies do not reoccur. Plan of correction implemented as of 8/25/2017. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
|
Observations
The facility failed to document that each medication order and subsequent dose and schedule change was written and signed by the narcotic treatment physician in seven of eight patient records reviewed on August 22-23, 2017.
Eight patient records were reviewed. All required medication orders. Patient records # 1, 2, 3, 4, 5, 6 and 8 had documented verbal orders. The physician was present at the facility at the time of the verbal orders. The orders were documented by the nurse and were not written by the physician.
Patient # 4 received take home medication bottles. There was no physician's order documented for take homes patient received within the time frame from June 12, 2017 to August 22, 2017.
Patient # 5 received take home medication. There was no physician's order documented for take homes patient received from February 7, 2017 to February 13, 2017.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/25/2017, Facility Director held a training with all medical staff/physicians on verbal orders and adherence to Echo Treatment Center's policy regarding verbal orders. Echo Treatment Center's operations manual section 715.17 (b) was reviewed and verbal orders will only be utilized according to policy and procedure. All medical/dispensing staff were also trained that before any subsequent dose and/or schedule change, or take home medication bottles are received by a patient, a physician's order, written, signed and dated by an ETC physician be present before the administration of medication. The Facility Director will perform random chart audits on a regular basis for compliance and to ensure these deficiencies do not reoccur. Plan of correction implemented on 8/25/2017. |