INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone/buprenorphine monitoring inspection conducted on January 6, 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:
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Plan of Correction
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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.
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Observations
Based on a review of the facility fire drill logs, the facility failed to ensure a fire alarm or a smoke detector was set off during each fire drill.
The January 2022 to December 2022 fire drill logs were reviewed. The facility failed to document a fire alarm or a smoke detector was set off during the fire drills for January 2022, May 2022, July 2022, August 2022, September 2022, and November 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All monthly drills will include both a smoke detector drill and a fire alarm drill and will be notated on the Safety Audit Log. A new sheet has been created to include both mechanisms for alert. The Project Director has updated policies and forms and will provide oversite each month. |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admission dates and discharge dates within a specific time period.
Record keeping system was not available at the time of the inspection due to server issues.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The new EMR will capture admit and discharge dates. If their are issues software wise or server wise the new EMR has cloud storage and all files are backed up daily and able to be accessed if any issues occur like power outages or anything catastrophic. The Clinical Director has oversight of this. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient ' s first 2 years in two of two applicable records reviewed.
Patient #1 was admitted on March 15, 2021 and was still active at the time of inspection. The record of service and the progress notes indicated one hour documented for November 2022.
Patient # 3 was admitted on January 8, 2021 and was still active at the time of inspection. The record of service and the progress notes indicated less than two hours of therapy for October, November and December 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The NEW EMR that is being installed has compliance configuration that it will alert the counselor if the patient is not meeting their required hours for outpatient counseling. The record of service and progress notes have to be completed after the session and the new EMR will not let you advance until all notes and notations are done. This will ensure compliance. The Clinical Director is responsible for oversight. |
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.
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Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and was reviewed, dated, and signed by the medical director in one of three applicable patient records reviewed.
Patient #2 was admitted on August 22, 2017 and was still active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on September 1, 2022; however, the evaluation was not reviewed, dated, and signed by the medical director.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All annual evals have been updated to reflect the Medical Directors signature will be populated on all Annual Evaluations. The new EMR has been configured for that compliance metric. The Clinical Director has oversight over this. |