INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 28, 2024 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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709.25 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 documents and an interview with the facility director, the project failed to document an annual financial audit for the fiscal year ending June 30, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Journey Health Systems and Deerfield Center for Addiction Treatment have activated a procedure to ensure that the annual fiscal policy audit will be completed for the previous year within 5 months of the prior year ending to ensure that documentation is available for licensure auditing in a timely manner.
The Chief Financial Officer of Journey Health will be responsible for the timeliness of this report and will monitor it via Alerts set the JHS financial system set for completion of report within 5 months of end of year report.
Journey Health received the completed report on 3/8/2024 from auditing firm.
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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 client records, the facility failed to include the type and frequency of treatment and rehabilitation services on the treatment plan in four of seven records.
Client #1 admitted on August 16, 2023and still a current client. The comprehensive treatment plan completed on September 27, 2023 did not include type or frequency of services.
Client #3 admitted on September 11, 2023 and still a current client. The comprehensive treatment plan completed on September 27, 2023 did not include type or frequency of services.
Client #4 admitted on September 21, 2023 and still a current client. The comprehensive treatment plan completed on September 27, 2023 did not include type or frequency of services.
Client #6 admitted on January 23, 2024 and still a current client. The comprehensive treatment plan completed on February 14, 2024 did not include type or frequency of services.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Deerfield Center for Addiction Treatment staff was retrained on 3/8/2024 on the requirements related to documenting a client's treatment frequency and duration within the master and updated treatment plans. This plan assigns the clinical supervisor to review all master and treatment plan updates at time of signature to ensure that the frequency and duration are appropriately completed. |