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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of training records, the facility failed to document the collection of feedback on completed training in one of one applicable record.
The policy and procedure states " ' Training feedback form ' will be completed by the staff member following each training program they attend."
Employee #3 was hired on September 16, 2016 and was the only employee applicable for completing the feedback forms for the training year from July 1, 2021 to June 30, 2022. No feedback forms were completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
At the direction of the Clinical Director Jean Berry, All Deerfield Behavioral Health Center for Addiction Treatment staff have been provided paper and digital copies of the Training Feedback form as of 3/3/2023 to be completed immediately after completing any training for their position. All staff has been provided training on completing the feedback form as of 3/3/2023. All clinical training will encompass the use of the feedback form as of 3/3/2023. The feedback form will be completed at the completion of the training engaged in by the individual clinicians and submitted to the Clinical Director on the day of completion. The Feedback forms will be reviewed weekly by the Clinical Director and filed for Auditing purposes. The Feedback Form will be attached to each clinician 2023-2024, and all future year individual training plans to ensure that the feedback form is completed at the time of training and submitted for weekly tracking by the clinical director of the program. |
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.
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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
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.
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