INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, methadone and buprenorphine monitoring inspections conducted on January 13-14, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Espers Treatment Center, Inc 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of personal records, the facility failed to ensure that staff received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in one of two personnel records. The findings include:Seven personnel records were reviewed on January 13-14, 2015. Two personnel records were reviewed for the completion of HIV/AIDS and sexually transmitted diseases training. Review of employee # 4's training showed that the employee did not receive the required hours of HIV/AIDS and tuberculosis, sexually transmitted diseases and other health related topics training.Employee # 4 was hired as a counselor on March 8, 2013. A minimum of 6 hours HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training was to be completed by March 4, 2014. The employee had only 3 hours of HIV/AIDS training and 3 hours of tuberculosis, sexually transmitted diseases and other health related topics training documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will search for and register the employees that do not have 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. The trainings will be completed within 6 months of hiring. The Clinical Director will sign all applicable employees up for the trainings as the trainings are offered. If a training is not offered in within a reasonable time frame the Clinical Director will get a hold of a representative from Gaudenzia to see if someone at that agency can offer the appropriate training. The training is always held in November. If it is not held within the specific time frame the agency will contact Gaudenzia and hold the training at the facility to ensure all hours are completed. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project/facility director in one of one personnel record.The findings include:Seven personnel records were reviewed on January 13-14, 2015. One personnel record pertained to the project/facility director. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.Employee # 1 has been the project/ facility director since July 2002. The facility training year reviewed was July 1, 2013 through June 30, 2014. Employee # 1 had 2 clock hours of annual training documented for the 2013-2014 training year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will register the Project Director and all other personnel for the trainings appropriate for their respective positions within the organizations. The Clinical Director will make sure all staff have the required number of training hours Quarterly. |
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.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training as required for counselors in one of four personnel records.The findings include:Seven personnel records were reviewed on January 13-14, 2015. Five personnel records pertained to counselors. Four personnel records required the completion of 25 clock hours of annual training. The training year for July 1, 2013 through June 30, 2014 was reviewed. The facility failed to document 25 clock hours of annual training in personnel record # 5. Employee # 5 was hired on August 22, 2006. Employee # 6 had 16.5 clock hours of annual training documented for the reviewed training year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will sign up all counselors and ancillary staff for the trainings required annually. Then the Clinical Director will follow up quarterly and see which staff members are deficient in training hours. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to document verification of the individuals identity, including name, address, date of birth, and other identifying data, in one of twelve patient records.The findings include:Twelve methadone patient records were reviewed on January 13-14, 2015. Twelve patient records were required to document verification of the individuals identity. One patient record did not include the documentation.Patient record # 1 was admitted on January 9, 2015. The initial dose of methadone was given to the patient on January 9, 2015. The facility failed to document verification of the individuals identity prior to the first administration. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Nursing Supervisor will ensure that a valid state ID is secured for each patient prior to new admission or transfer of an existing patient. No patient will be admitted without the verification of identity. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on the review of patient records, the facility failed to document that the narcotic treatment physician determined the proper dosage level for a patient in one of twelve patient records. The findings include:Twelve methadone patient records were reviewed on January 13-14, 2015. Twelve records were reviewed for documentaion that the narcotic treatment physician determined the proper dosage level for a patient. There was no documentation in patient record # 7 that the narcotic treatment physician determined the proper dosage level for the patient. Patient # 7 was admitted on May 11, 2011 and involuntarily discharged on October 7, 2014. The patient was given a detox dosing schedule and the patient's dose was decreased daily from September 30 - October 7, 2014 until the detox was complete. There was no documentation provided that the narcotic treatment physician had determined the dosing schedule. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All detox orders will be determined by the physician and documented by the physician. The nursing supervisor will ensure that all orders are documented in the chart. |