INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2025 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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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, the facility failed to ensure that one employee received the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment in one of one records.
Staff #6 was hired as counselor on December 4, 2023 and still employed at the time of inspection. Staff #6 was due to have the communicable disease trainings no later than December 4, 2024 but did not complete until January 31, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All training plans and training records will be reviewed regularly to ensure compliance. DDAP specific training requirements will be added to current HR electronic training platform (Relias) for additional monitoring and oversight. Staff disciplinary action will be taken for any noncompliance with requirements.
Person Responsible: Clinical Supervisor will review all training records with therapists and staff during weekly supervision meetings and complete any/all employee disciplinary procedures for noncompliance. This will begin immediately, 05/02/2025.
Clinical Supervisor also will meet with HR personnel responsible for adding trainings to the Relias system for tracking. This will be complete by June 1, 2025. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document what specific information could be disclosed on the consent to release form in one of seven records.
Client #5 admitted October 4, 2024 and still a current client. A release of information was signed on September 25, 2024 to an agency but did not indicate specific information to be disclosed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We are implementing 100% supervisory record review procedures to ensure compliance with all requirements related to the completion of documentation as soon as we are live in our new electronic health record (May 1, 2025). Staff will also be retrained in how to complete documentation correctly by May 2, 2025.
Person Responsible: Clinical Supervisor will review all documentation requirements with therapists and staff during the new electronic medical record training and during weekly supervision meetings. This will begin immediately, 05/02/2025.
Medical Records Department also will conduct random audits of medical records and report results to Clinical Supervisor so that she can address any ongoing training needs. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included purpose of disclosure in one of seven records reviewed.
Client #5 was admitted October 4, 2024 and still a current client. A release of information was signed to an agency which did not include purpose of disclosure on September 25, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We are implementing 100% supervisory record review procedures to ensure compliance with all requirements related to the completion of documentation as soon as we are live in our new electronic health record (May 1, 2025). Staff will also be retrained in how to complete documentation thoroughly and correctly by May 2, 2025.
Person Responsible: Clinical Supervisor, will review all documentation requirements with therapists and staff during the new electronic medical record training and during weekly supervision meetings. This will begin immediately, 05/02/2025.
Medical Records Department also will conduct random audits of medical records and report results to the Clinical Supervisor so that she can address any ongoing training needs. |