INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on January 29-30, 2025 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that includes all required information for completed fire drills.
Fire drill records were reviewed from January 2024 to December 2024. Fire drill logs completed in June and July failed to include evacuation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that a Fire Drill inclusive of an evacuation of patients and staff occurs monthly. This will occur on the same day that the monthly Environmental Check is performed. The PD will be in charge of the drills, evacuation and environmental check monthly at the facility and will be notated on monthly logs. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative information and staff interview, the project failed to document an annual financial audit for year 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will file an exception to DDAP to ask for a 6 month extension for the audit of 2024. If the exception is denied the PD will coordinate with the CPA to schedule an audit within 60 days of the prior fiscal year. |
709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
Based on a review of client records and staff interviews, the facility failed to ensure client records were readily accessible for a minimum of 4 years.
The facility switched electronic medical record systems in November 2023 and all client records previously kept in the electronic format prior to November 2023 are inaccessible.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director has contacted an attorney to send a letter to the previous EMR provider in an attempt to have all records available and all historical patient data be made available to ETC in a format that is downloadable into the new EMR. The attorney called on 2/24/25 and is waiting a call back. If the attorney doesn't get a reply by 3/7/25 the attorney has been advised to send a strongly worded to threatening pending litigation if the information is not released to ETC in a timely manner. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the facility failed to sign off on verbal medication orders within the required 3 business days in four of four records.
The facilities policy and procedure manual states verbal medication orders will be authenticated by physician within 24 hours.
Each client record had verbal medication orders entered by medical staff but not signed off by the ordering physician within 24 hours or 3 business days.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director has updated the P and P manual to include that Verbal Orders need signed off within 3 business days.
The PD has communicated with the current EMR provider to add an alert or flag to the doctors main screen to denote that verbal orders need signed off on prior to 3 days. The DON will have oversight of all verbal orders and will check orders daily to ensure compliance. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the facility failed to maintain a photograph of each patient including the patients name and date of birth and updated every three years in one of four patient records. Patient #4 was admitted July 28, 2020 and discharged November 29, 2024. The patient record failed to include a picture. This finding was reviewed with facility staff during the licensing process
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Plan of Correction
Patient photos will be captured at admission and uploaded into the EMR. An alert will be put into the EMR to capture the photo at the 3 year anniversary. The f PD will oversee all patient photos are being uploaded into the EMR on upon admission and every 3 years after admission. Patient photos are being updated and uploaded currently and will be complete by 3/12/25. |
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.
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Observations
Based on review of patient records, the facility failed to provide documentation of an annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in one of three patient records. Patient # 1 was admitted March 15, 2021 and still a current patient. An annual physical exam was due no later than March 15, 2024 however, the annual physical exam was not completed until November 7, 2024. These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Director of Nursing will schedule annual physicals prior to the anniversary of their admission date. The DON will coordinate with the physician 1 month prior to each patients anniversary date to schedule annual physical before the anniversary date. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans within 60 days in two of three client records.
Client #2 was admitted on November 22, 2021 and still a current client. A treatment plan was completed on July 1, 2024 and an update was due by August 30, 2024 but not completed until September 2, 2024. Additionally, another treatment plan was completed on November 1, 2024 and an update was due by December 31, 2024 but not completed until January 2, 2025.
Client #4 was admitted on July 27, 2020 and discharged on November 29, 2024. A treatment plan was completed on July 12, 2024 and an update was due by September 10, 2024 but not completed until November 29, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure that each Treatment Plan is reviewed within 60 days and that will be notated in the Plan and the Progress note. The CD addressed the Clinical Team and going forward all TX Plan Updates will be input into the EMR scheduler and notify the Counselor one week prior to notify of TX Plan update needed. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure the clients received counseling services according to their individual treatment plan in one of two applicable records.
Client #2 admitted on November 22, 2021 and still a current client. The client ' s treatment plan update completed on November 1, 2024 indicated the client would receive individual counseling once per week. The client did not receive counseling the following weeks: November 3, November 10, November 17, November 24, December 8, December 15, December 22, January 5, January 12, and January 19, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure each Treatment Plan contains an objective verifying the type and frequency of counseling services individualized for each patient and their needs. The Clinical Director will review progress on meeting counseling requirements and will track compliance monthly. During the Clinical Supervision meetings, The CD will have each Counselor bring 3 TX Plans to the supervision meeting and The CD and Counselor will look at all interventions and actions on the Tx Plan and ensure that the services received are congruent with their Current TX Plan. |