INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7 - 9, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Esper 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 and a plan of correction is due on September 5, 2007.
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Plan of Correction
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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 the administrative documentation for staff training it was determined that the facility failed to provide the required documentation of counselor training hours. Personnel records # 4, 6 and 8 have less than 25 hours of training for the July 2006 to June 2007 training year.
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Plan of Correction
The Esper Treatment Center did not have a formal system of reviewing counselor's training hours throughout the year on an ongoing basis. As of September 3, 2007, we have incorporated a separate agenda item on our Senior Management Team Agenda call Staff Training Hours as a vehicle to track the staff training hours throughout the year every two-weeks. Our Clinical Director will keep track of the training hours and report the status at our meetings. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of administrative documentation for staff training, it was determined that the facility failed to provide the required training hours for employee #5.
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Plan of Correction
The Esper Treatment Center did not have a formal system of reviewing counselor's training hours throughout the year on an ongoing basis. As of September 3, 2007, we have incorporated a separate agenda item on our Senior Management Team Agenda call Staff Training Hours as a vehicle to track the staff training hours throughout the year every two-weeks. Our Clinical Director will keep track of the training hours and report the status at our meetings. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records it was determined that the facility failed to provide individualized treatment plans for client records # 3, 4, 6 and 11. The first comprehensive plan is the same for all of these patients. Chart # 12 did not have a comprehensive treatment plan.
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Plan of Correction
In 2006 /2007, Esper Treatment Center started a group for patients who are in denial of their other than opioids drug abuse. This group is designed to give our patient in this category basic Drug & Alcohol abuse/dependency information to aide the patient in their denial. Our Clinical Director designed a standardizes treatment plan to address this group. In the cases of patients # 3, 4, 6, and 11 their counselors did not identify or address on initial comprehensive treatment plan any other problem area to address while the patients were going to the group.
On August 13, 2007 our Clinical Director redesigned all standardized group plan to include a place for an individual problem area to be addressed while the patient is going trough groups. On August 13, 2007 at our Clinical Peer Review Meeting, our Clinical Director informed the staff that they are require to address an individual problem in conjunction with the group plan and informed the counselors that she would not sign off on a group plan if there is not an individual problem being address.
In chart # 12 a new counselor/employee was under the wrong impression that she had more than the 30-days to complete the Comprehensive Treatment Plan. Our Clinical Director reeducated the counselor and reminded all staff in the August 13, 2007 at our Clinical Peer Review Meeting that Comprehensive Treatment Plan is due within 30-days of admission. Our Clinical Director will be responsible for follow-up to ensure all admission shall have a Comprehensive Treatment Plan within 30-days of admission. She will check this is being done through our 30-day Admission List.
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