INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on January 27-28, 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 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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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 eight of eight 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. |
715.9(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 a review of patient records, the facility failed to verify an individual ' s identity, including name, address, date of birth, emergency contact, and other identifying data prior to the administration of an agent in one of eight records. Patient #2 was admitted April 24, 2024 and discharged December 11, 2024. There was no verification of the patient ' s identity in the patient record at the time of the inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of a patient will be requested on the day of the Preadmission Assessment by the Front Desk staff. The Front Desk staff will ask for a State issued ID for verification and upload the ID into the EMR. Upon admission the Front Desk staff will take a photo of the patient and upload it into the EMR. The PD will ensure that all ID |
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 three of eight patient records. Patient #2 was admitted April 24, 2024 and discharged December 11, 2024. The patient record failed to include a picture. Patient #3 was admitted September 15, 2023 and discharged September 15, 2024. The patient record failed to include a picture.Patient #6 was admitted June 18, 2024 and still a current patient. The patient record failed to ensure the picture was updated in the past three years. 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 front desk staff 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. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document transfer of patient files to the patient's new treatment facility in one out of one applicable record. Patient #8 was admitted on January 14, 2022 and transferred to another facility on September 19, 2024. At the time of the inspection, there was no documentation that the facility transferred required patient files besides the dosing history.This finding was reviewed with facility staff during the licensing inspection
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Plan of Correction
For any transfers in or out of the facility, a Tracking form has been created that includes all requested parts of the patients file that need faxed over to the new facility to ensure the transfer PPW is complete. The Director of Nursing will ensure all paperwork gets faxed to the transferring clinic. The form has already been implemented. |
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 three of eight client records. Client #5 was admitted on March 12, 2024 and discharged on November 8, 2024. A treatment plan was completed on June 21, 2024 and an update was due by August 20, 2024 but not completed until August 29, 2024.Client #6 was admitted on June 18, 2024 and still a current client. A treatment plan was completed on July 10, 2024 and an update was due by September 8, 2024 but not completed until September 11, 2024. Client #7 was admitted on June 10, 2024 and still a current client. A treatment plan was completed on June 25, 2024 and an update was due by August 24, 2024 but not completed until September 10, 2024. Additionally, another treatment plan was due by November 9, 2024 but not completed until January 6, 2025.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 three of eight records. Each treatment plan indicated that therapy should be provided for 2.5 hours per month.Client #1 admitted on November 20, 2023 and discharged on October 16, 2024. The client did not receive 2.5 hours of counseling during the following months: April 2024, June 2024, August 2024, and September 2024.Client #2 admitted on April 24, 2024 and discharged on December 11, 2024. The client did not receive 2.5 hours of counseling during the following months: July 2024 and September 2024.Client #6 admitted on June 18, 2024 and still a current client. The client did not receive 2.5 hours of counseling during the following months: July 2024 and August 2024.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. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document an attempted follow up with clients following discharge from the facility in one of three applicable records reviewed. According to agency policy and procedure manual, follow up with discharged clients is as follows is completed within 90 days. Client #1 admitted on November 20, 2023 and discharged on October 16, 2024. Follow up was due by January 16, 2025 but no follow up attempts were documented for this client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The medical department will notify the Admin Assistant if a patient is leaving treatment. The Admin Assistant will send out a follow up letter within 30 days of patients departure. A log will be kept by the Admin Assistant and reconcile responses that ETC receives from patients that have left treatment for any reason. |