INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 29, 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 for the previous year is completed within 5 months of the prior year's ending. This ensures 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 in the JHS financial system set for completion of the report within 5 months of the end-of-year report.
Journey Health System received the completed audit of financial records on 3/8/2024 |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client which includes name of the person, agency, or organization to whom disclosure is made in one of seven records.
Client #3 admitted on October 12, 2023 and still a current client. Client record contained two release of information forms dated October 13, 2023 that did not contain the name of the person, agency, or organization to whom disclosure is made.
These findings were reviewed with 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.
The facility is committed to ensuring that deficiencies related to consent are addressed comprehensively and do not reoccur. To achieve this, we have implemented a rigorous oversight and review process whereby all admitted and pending admission charts are thoroughly examined by our Clinical Supervisor. This proactive measure ensures that consent protocols are adhered to consistently, and any deficiencies are promptly identified and remedied. Through continuous monitoring and assessment, we strive to uphold the highest standards of patient care and ethical practice. |