INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on December 4, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Esper Treatment Center 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:
|
Plan of Correction
|
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that at least one person trained in CPR and first aid is onsite during project's working hours. There are no staff with current CPR certification.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Project Director has scheduled CPR staff for all staff that works in Corry to ensure that staff on site is certified in CPR and first aid. The training will occur on January 18th at the Erie office and will include the 2 staff members that are not certified in CPR and First Aid. The pharmacist is certified in CPR and First Aid. The counselor and Project Director will be certified on January 18th. New staff that may be hired for the Corry facility will be certified in CPR and First Aid within 2 months of hire and the Corry office will always be staffed with at least one CPR/First Aid certified staff member at all times. |
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #3 was hired as a counselor on September 1, 2002 and was still in the position as of the date of the inspection. Employee # 3's record only document 22.5 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The clinical director and each counselor will develop an annual training plan consisting of 25 clock hours of training. Group and individual supervision sessions will be utilized throughout that year to track progress and ensure the hours are met annually. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical site inspection, the facility failed to ensure that fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher located by the side exit was last inspected in November, 2022.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The PD will ensure that all extinguishers are serviced annually and the actual number of extinguishers are picked up by Fireline and returned by Fireline. The PD realized that they forgot overlooked the 4th extinguisher and that fourth extinguisher has been serviced and the tag is updated to reflect such. To ensure compliance Fireline will service the Corry extinguishers a month before they service the Erie extinguisher. The PD will ensure they service all four extinguishers annually in Corry every October and the extinguishers in Erie every November. Each facility will have the same number of extinguishers on-site at each location serviced annually on separate months. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of the January, 2023 through November, 2023 fire drill logs during the inspection, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill. Fire drill logs for January 7, February 19, May 23, August 30 and October 25, 2023 did not indicate that a fire alarm or smoke detector was set off during the drill/
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the January 2, 2023 licensing review.
|
Plan of Correction
The PD will submit an exception to DDAP for an exception to use an audible device in lieu of setting off the fire alarm monthly for the Corry location. The PD and Clinical Director will ensure that all smoke alarms/ detectors are in operable condition each month. The PA system will be used to conduct monthly drills in lieu of setting off the smoke alarms. The exception will be submitted by 1/12/24. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
|
Observations
Based on the review of patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician within the regulatory timeframe in one out of four applicable records reviewed.
Patient #1 was admitted on July 27, 2020 and was still active at the time of the inspection. An annual physical was due no later than July 27, 2023; however, it was not completed until October 23, 2023.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Physician will ensure that all annual reevaluations are completed no later than the anniversary of the Month and day the patient was admitted to the program. The Director of Nursing will ensure all Annuals are completed on time and will schedule the Annuals for the NTP Physician prior to their anniversary date of admission. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
|
Observations
Based on the review of patient records, the facility failed to document an annual clinical evaluation with all areas of regulation addressed within the regulatory timeframe in one out of four applicable records reviewed.
Patient #1 was admitted on July 27, 2020 and was still active at the time of the inspection. An annual clinical evaluation was due no later than July 27, 2023; however, it was not completed until August 14, 2023. Additionally, it was not signed by the medical director.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the January 2, 2023 licensing review.
|
Plan of Correction
Clinical Director will review policy on completing Annual Clinical Evaluations by or prior to anniversary of admission date with staff. Clinical Director will randomly check compliance and review in individual supervision sessions with staff.
|