INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 8, 2017 by staff from the Division of Accountability and Program Improvement. Based on the findings of the on-site complaint investigation, Echo Treatment Center, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.28(c)(2) 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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
A review of charts was conducted on February 8, 2017. Based on this review, it was determined that Echo Treatment Center, LLC failed to obtain an informed and voluntary consent from a client for the disclosure of information contained in the client record. The consent did not include the specific information to be disclosed.
Client #2's file contained two consents both dated January 8, 2017. The consents for the Department of Public Welfare and Value Behavioral Health contained no specific information to be disclosed.
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Plan of Correction
On 2/13/2017, Clinical Supervisor conducted a staff meeting with all clinical personnel and reviewed the confidentiality policy and procedures including the accurate completion of consents to release information's. Clinical Supervisor at the meeting conducted a training which included the proper documentation and the information to be disclosed on the consents to release information's. Clinical Supervisor will conduct random chart reviews to ensure compliance with this procedure and to ensure this deficiency does not reoccur. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
A review of charts was conducted on February 8, 2017. Based on this review, it was determined that Echo Treatment Center, LLC's treatment plans failed identify the behavioral tasks a patient shall perform to compete each short term treatment goal.
Client #2's treatment plan dated January 30, 2017 did not specify the amount of treatment required by this client on a monthly basis.
Client #3's treatment plan dated December 13, 2016 did not specify the amount of treatment required by this client on a monthly basis.
Client #4's treatment plans dated June 13, 2016, November 29, 2016 and January 27, 2017 did not specify the amount of treatment required by this client on a monthly basis.
Client #5's treatment plan dated February 7, 2017 did not specify the amount of treatment required by this client on a monthly basis.
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Plan of Correction
On 2/13/2017, Clinical Supervisor conducted a staff meeting with all clinical personnel and reviewed the treatment plan process. Clinical Supervisor trained all staff in the proper formulation and documentation of treatment plans which must include the amount treatment required monthly. Clinical Supervisor will conduct random chart reviews to ensure compliance with this procedure and to ensure this deficiency does not reoccur. |