INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on December 21 - 22, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site 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 this inspection:
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Plan of Correction
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715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document the transfer of the required patient files to the receiving narcotic treatment program in one of one patient records reviewed on December 22, 2020.
Patient # 7 was admitted July 23, 2019 and discharged July 7, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will train staff on how to document that client records were transferred to the receiving narcotic treatment program and a copy of the fax sheet will be included in the client record. The facility director will complete random chart audits on clients that are transferred out to ensure the required documents were sent to the receiving program and documentation was kept in the record. The facility will correct this deficiency by January 15, 2021. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient in three of three patient records reviewed on December 21 - 22, 2020.
Client # 2 was admitted September 1, 2020.
Client # 4 was admitted August 19, 2020.
Client # 5 was admitted July 13, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility nurse will document in writing that the transferring narcotic treatment program was notified of the admission of the client and the date of the initial dose given. The facility director will complete random chart audits on clients that are transferred in ensure the required documents were sent to the previous treatment program and documentation was kept in the record. The facility will correct this deficiency by January 15, 2021. |