INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addictions Treatment 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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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of the administrative information, the facility failed to include a statement disclosing the names of the Board of Directors in the 2022 annual report.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Journey Health Systems administrative staff has formally updated the 2022 Annual report to amend the missing information related to Deerfield Behavioral Health Board of Directors. A formal list of the Deerfield Board of Directors has been listed in the Annual Report of 2022 on the Deerfield Behavioral Health website and Journey Health System website as of 3/6/2023.
Journey Health Systems plan to ensure that this failure to notify the state of any future changes is as follows:
The Director of Risk and The Chief Financial Officer will take departmental and program responsibility for direct communication and notification of any future Affiliation changes by use of posted form on the DDAP website and ensure that notification and communication are completed within 90 day period required. |
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 four of four applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records #1, #2, #3, and #4.
Client #1 was admitted to outpatient on July 15, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan update was due no later than December 13, 2022, but was not completed until February 16, 2023.
Client #2 was admitted to outpatient on April 28, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 5, 2022. A treatment and rehabilitation plan update was due no later than August 5, 2022, but was not completed until August 11, 2022.A treatment and rehabilitation plan was developed on August 11, 2022. A treatment and rehabilitation plan update was due no later than October 11, 2022, but was not completed until November 3, 2022.A treatment and rehabilitation plan was developed on November 3, 2022. A treatment and rehabilitation plan update was due no later than January 3, 2023, but was not completed until January 12, 2023.
Client #3 was admitted to outpatient on September 22, 2022 and discharged on January 26, 2023. A treatment and rehabilitation plan was developed on November 3, 2022. A treatment and rehabilitation plan update was due no later than January 3, 2023, but was not completed until January 12, 2023.
Client #4 was admitted to outpatient on June 28, 2022 and discharged on January 5, 2023. A treatment and rehabilitation plan was developed on July 14, 2022. A treatment and rehabilitation plan update was due no later than September 14, 2022, but was not completed until September 22, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As identified in the Licensure Audit, no alerting system was found to be in place related to notifying staff of case consults, treatment plans and updates being due in a timely manner. A formal client tracker was developed and implemented on 3/6/2023 by the Director of the program to indicate the due date of Case Consultations, Treatment plan updates and ASAM level of care updates for each client. Clinical staff was provided education on the completion of Treatment plans for IOP every 30 days, OP treatment plans every 60 days, ASAM level of Care continued stay forms every 30 days of IOP and every 60 days for OP, as well as Case Consults every 60 days. Training and education provided to all staff on the requirements related to signatures and the overlapping/ different requirements related to the client's funder was provided. All staff are required to submit the client tracker related to Treatment plan dates, Case Consults and ASAM continued stay dates each Monday of the week for review and oversight by the Clinical Director. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on four of five applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a case consultation to occur every thirty days for intensive outpatient clients and every sixty days for outpatient clients.
Client #1 was admitted to outpatient on July 15, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than September 15, 2022, but was not completed until February 16, 2023.
Client #2 was admitted to outpatient on April 28, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than June 29, 2022, but was not completed until September 16, 2022.A case consultation was due to occur no later than November 16, 2022, but was not completed until December 28, 2022.
Client #3 was admitted to outpatient on September 22, 2022 and discharged on January 26, 2023. A case consultation was due to occur no later than November 22, 2022, but case consult was not in record at the time of the inspection.
Client #4 was admitted to outpatient on June 28, 2022 and discharged on January 5, 2023. A case consultation was due to occur no later than August 28, 2022, but was not completed until September 22, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As identified in the Licensure Audit, no alerting system was found to be in place related to notifying staff of case consults, treatment plans, and updates being due in a timely manner. A formal client tracker was developed and implemented on 3/6/2023 by the program's Director to indicate the due date of Case Consultations, Treatment plan updates, and ASAM level of care updates for each client. Clinical staff was provided education on the completion of Treatment plans for IOP every 30 days; OP treatment plans every 60 days, ASAM level of Care continued stay forms every 30 days of IOP and every 60 days for OP, and Case Consults every 60 days. Training and education provided to all staff on the requirements related to signatures and the overlapping/ different requirements related to the client's funder were provided. All staff must submit the client tracker related to Treatment plan dates, Case Consults, and ASAM continued stay dates each Monday of the week for review and oversight by the Clinical Director. |
709.14(b)(1) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
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Observations
Based on a review of the administrative information and discussions with facility staff, the facility failed to notify the Department within 90 days of a change of ownership.
The change of ownership occurred in December 2020 and the Department was not notified.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Team of Journey Health Systems will address the deficiency related to not notifying the DDAP and the Pennsylvania Department of State of the change of ownership. The Executive team will complete and submit all documentation requested in correspondence from DDAP dated 3/14/2023 related to affiliation and ownership change by 5/1/2023. A formal updated organizational chart reflecting the previous and current organization will be submitted to RA Account by 5/1/2023. |