INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 27, 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.
Financial Report completed by auditor received by Journey Health on 3/8/2023. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one of seven records.
Client #6 admitted on November 6, 2023 and still a current client. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
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 all consents, completion of consents, signatures on consents, and consents that were declined to ensure that no records would be released to 3rd parties or insurance agencies without proper signatures and permission from the client. This plan assigns the clinical supervisor to review incoming admissions for properly completed consents and complete the admission once reviewed. |
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 #4 admitted on October 31, 2023 and still a current client. The comprehensive treatment plan completed on November 10, 2023 did not include type or frequency of services.
Client #5 admitted on September 21, 2023 and still a current client. The comprehensive treatment plan completed on October 16, 2023 did not include type or frequency of services.
Client #6 admitted on November 6, 2023 and still a current client. The comprehensive treatment plan completed on December 14, 2023 did not include type or frequency of services.
Client #7 admitted on October 12, 2023 and still a current client. The comprehensive treatment plan completed on October 23, 2023 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 incoming admissions for properly completed consents and complete the admission once reviewed. |