INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on December 5-6, 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 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(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 Staffing Requirements Facility Summary Report and personnel files, 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.
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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. |
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 patients with 2.5 hours of psychotherapy per month during the patient's first two years of treatment, one hour of which shall be individual psychotherapy, in two out of five applicable records reviewed.Patient #3 was admitted on January 6, 2023 and was still active at the time of the inspection. In November 2023, the patient received two hours of individual psychotherapy sessions and no groups. In September 2023, the patient received two hours of individual psychotherapy and no groups. Patient #5 was admitted on December 22, 2021 and was still active at the time of the inspection. In October 2023, the patient receive two hours individual psychotherapy sessions and no groups. These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the January 6, 2023 licensing inspection.
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Plan of Correction
Clinical Director will review the monthly psychotherapy hour requirements based on the patient`s years in treatment with each staff member. Individual supervision sessions will be utilized monthly to review compliance. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the patient records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the patient. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in one out of three applicable records reviewed. Patient #7 was admitted on May 5, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on May 12, 2023 with no type or frequency identified.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director will provide review of treatment planning with staff in a group counseling session. Clinical Director utilizes individual supervision sessions to review treatment plans ensuring that they contain both type and frequency. |