INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 1, 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 #5 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 trainings 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 program's clinical director.
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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.
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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 seven applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records #3 and #7. The facility also failed to update the treatment and rehabilitation plan at least every thirty days in client records #2 and #6, per intensive outpatient program policy.
Client #2 was admitted to intensive outpatient on October 31, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on December 12, 2022. A treatment and rehabilitation plan update was due no later than January 12, 2023,but was not completed until February 13, 2023.
Client #3 was admitted to outpatient on July 27, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on September 27, 2022. A treatment and rehabilitation plan update was due no later than November 27, 2022, but was not completed until December 13, 2022.
Client #6 was admitted to intensive outpatient on September 6, 2022 and discharged on December 8, 2022. A treatment and rehabilitation plan was developed on August 10, 2022. A treatment and rehabilitation plan update was due no later than September 10, 2022, but was not completed until October 5, 2022. A treatment and rehabilitation plan was developed on October 5, 2022. A treatment and rehabilitation plan update was due no later than November 5, 2022, but was not completed until December 2, 2022.
Client #7 was admitted to outpatient on June 24, 2022 and discharged on December 30, 2022. A treatment and rehabilitation plan was developed on August 10, 2022. A treatment and rehabilitation plan update was due no later than October 10, 2022, but was not completed until October 25, 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 five of seven 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 #2 was admitted to intensive outpatient on October 31, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than December 1, 2022, but was not completed until December 12, 2022.A case consultation was due to occur no later than January 12, 2023, but was not completed until February 13, 2023.
Client #3 was admitted to outpatient on July 27, 2022 and was still active at the time of the inspection. A case consultation was due to occur no later than December 1, 2022, but was not completed until December 13, 2022.
Client #4 was admitted to outpatient on May 12, 2022 and discharged on November 14, 2022. A case consultation was due to occur no later than July 12, 2022, but was not completed until August 10, 2022.
Client #6 was admitted to intensive outpatient from another program on September 6, 2022 and discharged on December 8, 2022. A case consultation was due to occur no later than September 10, 2022, but was not completed until September 28, 2022.A case consultation was due to occur no later than October 28, 2022, but was not completed until December 2, 2022.
Client #7 was admitted on June 24, 2022 and discharged on December 30, 2022. A case consultation was due to occur no later than August 21, 2022, but was not completed until October 25, 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. |
709.14(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 organization and current organization will be submitted to RA Account by 5/1/2023. |