INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone/buprenorphine monitoring inspection conducted on January 4-6, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document each counselor met both the educational and experiential qualifications for the position in one of two records reviewed. Employee # 4 was hired as a counselor on August 29, 2022 and was still in the position at the time of the inspection. The employee ' s resume did not include documentation of at least one year of clinical experience for an employee with a bachelor's degree. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to the hiring of Clinical Staff each candidate resume will be reviewed to quantify if the candidate is appropriate for the clinical position, both educationally and experience wise. Candidates that do not meet the educational and experience benchmarks set forth by the licensing regulations will not be interviewed or hired. The Project Director and Clinical Director are responsible for ensuring all potential new hires have the appropriate education and experience prior to offering employment. |
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 a review of personnel records and the facility ' s Staffing Requirements Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of five applicable records reviewed. Employee #5 was hired as support staff in January 2018 and was due to have the HIV/AIDS and TB/STD training by January 2020. As of the date of the inspection, documentation was not provided.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff inclusive of ancillary staff will receive the Mandatory HIV/AIDS TB/STD within the first quarter of employment. The Clinical Director will schedule trainings for new staff as they are hired and will utilize the Dept of Health and Central Outreach if a local training is not available. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's February 2022 through January 2023 unusual incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of ambulance personnel at the facility on July 7, 2022 and November 21, 2022. As of the date of the inspection, the two incidents were not reported to the Department. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure all unusual incidents are reported to DDAP in a timely fashion. If an incident occurs and the Project Director is unavailable or unable to submit the report the Clinical Director will be responsible for reporting the Unusual Incident to DDAP. All reporting will be done within 24 hours of incident. A log will be kept yearly with all unusual incidents reported. |
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 each patient an average of 2.5 hours of psychotherapy per month during the patient ' s first 2 years in three of six records reviewed. Patient #1 was admitted on December 22, 2021 and was still active at the time of inspection. The record of service and the progress notes indicated two hours of therapy for October 2022, two hours of therapy for November 2022 and two hours of therapy for December 2022.Patient # 2 was admitted on September 13, 2022 and was still active at the time of inspection. The record of service and the progress notes indicated two hours of therapy for November 2022 and two hours of therapy for December 2022.Patient #6 was admitted on April 4, 2022 and was still active at the time of inspection. The record of service and the progress notes indicated two hours of therapy for October 2022, two hours of therapy for November 2022 and two hours of therapy for December 2022.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will ensure that all Counselors are providing the psychotherapy hours for each patient each month. The Clinical Director will go through each counselor's caseload, with the counselor, during the weekly supervision sessions to ensure the counselor is providing the appropriate hours of psychotherapy services each month and to ensure compliance with DDAP. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient's counselor and was reviewed, dated, and signed by the medical director in two of two applicable patient records reviewed. Patient #1 was admitted on December 22, 2021 and was still active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on December 19, 2022; however, the evaluation was not reviewed, dated, and signed by the medical director. Patient #5 was admitted on November 1, 2021 and was still active at the time of inspection. The annual evaluation of the patient's status was completed by the counselor on November 30, 2022; however, the evaluation was not reviewed, dated, and signed by the medical director. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All annual evaluations have been changed in the EMR to ensure compliance. The EMR will not allow an annual evaluation to be completed unless all appropriate parties sign the evaluation. The EMR will only allow the Medical Director to sign and acknowledge the annual evaluation. The Project Director and Clinical Director will ensure compliance. |
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 assure clients received counseling services according to the individual's treatment and rehabilitation plan in three of six records reviewed. Client #1 was admitted on December 22, 2021 and was still active at the time of inspection. The individual treatment plan indicated 2.5 hours of therapy per month. The client's record of service and progress notes indicated the client did not receive services according to the treatment plan for October 2022, November 2022 and December 2022; only 2 hours of therapy per month for each month is documented. Client # 2 was admitted on September 13, 2022 and was still active at the time of inspection. The individual treatment plan indicated 2.5 hours of therapy per month. The client's record of service and progress notes indicated the client did not receive services according to the treatment plan for November 2022 and December 2022; only 2 hours of therapy per month for each month is documented.Client #6 was admitted on April 4, 2022 and was still active at the time of inspection. The individual treatment plan indicated 2.5 hours of therapy per month. The client's record of service and progress notes indicated the client did not receive services according to the treatment plan for October 2022, November 2022 and December 2022; only 2 hours of therapy per month for each month is documented.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will have all counselors brings their caseload and hours met with the patient every week for their supervision contact and audit the hours for compliance that all patients are receiving 2.5 hours of counseling a month. The Clinical Director will ensure all hours are met and created a tracking sheet for each patient and their level of OP counseling requirements. |