INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4, 2026 through March 5, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Coatesville Comprehensive Treatment Center 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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709.28 (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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in four of eight records reviewed.
Client #2 was admitted on June 16, 2021 and was active at the time of the inspection. The facility failed to document a release of information for the funding source, and it was verified that billing had occurred.
Client #5 was admitted on January 28, 2025 and was discharged on February 4, 2026. The facility failed to document a release of information for the funding source, and it was verified that billing had occurred.
Client #6 was admitted on July 11, 2017 and was discharged on January 2, 2026. The facility failed to document a release of information for the funding source, and it was verified that billing had occurred.
Client #7 was admitted on November 11, 2010 and was active at the time of the inspection. The facility failed to document a release of information for the funding source, and it was verified that billing had occurred.
This is a repeat citation from the March 7, 2025, March 29, 2024, and March 31, 2023 annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Effective immediately, the facility conducted a record‑specific review of the clients identified in this deficiency.
Client #2, who was admitted on June 16, 2021 and active at the time of the inspection, was brought into compliance on March 10, 2026, when a valid, informed, and voluntary Release of Information (ROI) for the funding source was obtained and properly documented in the client record. Verification was completed prior to any further disclosure or billing activity.
Client #7, who was admitted on November 11, 2010 and active at the time of the inspection, is scheduled to be brought into compliance on April 8, 2027, at which time a valid, informed, and voluntary Release of Information (ROI) for the funding source will be obtained and documented in the client record. The facility will ensure that no disclosure of information occurs without appropriate consent.
In addition to addressing the identified records, all active client records are being audited to ensure the presence of a valid ROI for the funding source. Any missing, expired, or incomplete ROIs are corrected promptly upon identification. All new admissions and readmissions require verification of a valid ROI prior to admission finalization and prior to any billing or disclosure of information.
The facility utilizes an Electronic Health Record (EHR) hard‑hold to prevent admission completion when a required ROI is not present or valid. The ROI requirement is embedded in the admission checklist and is verified by counseling staff and the Administrative Assistant, with oversight by the Clinical Supervisor.
Responsibility for implementation and ongoing oversight is shared among the Clinic Director, Clinical Supervisor, Administrative Assistant, and counseling staff. Compliance is monitored through daily review of new admissions, weekly supervision review, monthly tracking, and inclusion of ROI verification in annual client record reviews. Any identified deficiencies are addressed promptly through corrective action, retraining, and supervisory follow‑up to ensure sustained compliance. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the program failed to verify a patient's identity, which included the name, address, date of birth, emergency contact and other identifying information prior to the administration of an agent in one of eight records reviewed.
Client #5 was admitted on January 28, 2025 and was discharged on February 4, 2026. There was no documentation of the patient' s emergency contact prior to the administration of an agent.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Effective immediately, and to be fully implemented within 7 business days, all active patient records will be audited to confirm the presence of complete identifying information, including name, address, date of birth, and emergency contact, with any missing information obtained and documented accordingly in the Pt.'s record.
A revised intake and dosing protocol to include verification of all required identifying data prior to admission finalization.
Utilization of the EHR hard hold system will be in effect to assist with the correction to any areas identified as deficient.
Responsibility for implementation will be shared by the Clinic Director, Administrative Assistant and Charge Nurse, with intake staff responsible for collecting and documenting all required identifying information at admission.
The Clinic Supervisor and Clinical Director will monitor compliance through weekly audits of a new patient charts, specifically reviewing completeness of identifying information, with findings reviewed in supervision and leadership meetings. Ongoing compliance will be tracked monthly with a goal of 100% completion, and any deficiencies will be addressed immediately through staff retraining and progressive accountability measures to ensure sustained adherence to regulatory requirements. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the program failed to complete an initial drug screening urinalysis for each prospective patient in one of eight records reviewed.
Client #4 was admitted on May 5, 2025 and was discharged September 3, 2025. A urinalysis was not completed util May 19, 2025.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
Effective immediately all active patient records will be reviewed to verify that an initial urinalysis was completed timely, with any discrepancies addressed and documented.
During admission nursing will ensure an initial urinalysis is completed on the day of admission and such will be verified by the intake counselor.
Responsibility will be shared by the Clinic Director, Clinical Supervisor and Charge Nurse, with nursing staff responsible for completing and documenting the urinalysis at admission and intake staff responsible for ensuring the requirement is included in the admission checklist.
The Charge Nurse and Clinical Supervisor will monitor compliance through weekly audits of a minimum of new patient charts, specifically comparing admission dates to urinalysis completion dates, with findings reviewed in supervision and leadership meetings.
Ongoing compliance will be tracked monthly with a goal of 100% timely completion of initial urinalysis, and any deficiencies will be addressed immediately through staff retraining and progressive accountability measures to ensure sustained adherence to regulatory requirements. |
715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the program failed to document the transfer of a patient file that included admission date, urinalysis reports or summary, exception requests and current status of the patient in one out of one applicable patient record reviewed.
Client #5 was admitted on January 28, 2025 and was transferred to another program on February 4, 2026. There was no documentation that the facility transferred the patient ' s file to the receiving program.
These findings were reviewed with program staff during the licensing process.
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Plan of Correction
In an effort to ensure compliance, all recent patient transfers within the past 90 days will be audited by respective counseling staff and the Clinical Supervisor to verify that complete transfer documentation is present.
Any missing documentation will be obtained, corrected and filed in the patient record.
The existing standardized transfer protocol and checklist requiring that all required documents are compiled, transmitted to the receiving program, and documented in the patient record at the time of transfer will be reviewed by the Clinic Director and Clinical Supervisor at the time of the Pt. request for transfer, and immediately following the Pt. transfer.
Responsibility for implementation will be shared by the Clinic Director and Clinical Supervisor, with counselors responsible for preparing and documenting transfer packets and administrative staff responsible for confirming transmission and documentation.
The Clinic Director and Clinical Supervisor will monitor compliance through real-time day of transfer audits as well as weekly audit reviews for all transfers occurring during the review period.
All findings will be reviewed during weekly supervision and leadership meetings.
Ongoing compliance will be tracked monthly with a goal of 100% complete and documented transfers, and any deficiencies will be addressed immediately through staff retraining and progressive accountability measures to ensure sustained adherence to regulatory requirements. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of the unusual incident log, the program failed to file a written unusual incident report with the Department within 48 hours following an unusual incident involving a death or serious injury due to trauma, suicide, mediation error or unusual circumstances.
On April 14, 2025, September 2, 2025, February 9, 2025, and February 24, 2025, the program was notified of four separate patient deaths. Written unusual incident reports were not filed with the Department.
This finding was reviewed with program staff during the licensing process.
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Plan of Correction
To ensure this deficiency does not recur, the Clinic Director will implement and enforce compliance with regulation 715.28(c) (1?5) Licensure regarding unusual incident reporting commencing with the review of such during the Monthly All staff meeting.
A review of the need for timely and effective communication on site will be discussed in order to ensure corrective measures are in place with regards of internal communication.
The Clinical Supervisor will ensure that all necessary notifications are completed and that the necessary notifications are prepared.
As the designated party, the Clinic Director will ensure that a written unusual incident report is submitted, and the information is entered into DDAP portal within an internal timeframe of 24 - 48 hours.
The Clinic Director is responsible for oversight of the process, with a designated backup to ensure continuous coverage.
All staff will be trained are informed on the requirements of 715.28(c) (1?5), and compliance will be monitored weekly and reported monthly, with a goal of 100% adherence. Any failure to comply will be addressed immediately through corrective action and progressive accountability measures to ensure sustained compliance with regulatory requirements.
The unusual incident reports dated 2/9/2025, 2/24/2025, 4/14/2025 and 9/2/2025 were submitted on 4/16/2026. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in five of eight records reviewed.
Client #1 was admitted on May 7, 2024 and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan update, documented in the client record on April 22, 2025, indicated that the client was to receive one hour of individual counseling sessions per month; however, there were no individual counseling sessions from the months of June 2025, July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, January 2026 and February 2026.
Client #2 was admitted on June 16, 2021 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan update, documented in the client record on May 7, 2025, indicated that the client was to receive one hour of individual counseling sessions per month; however, there were no individual counseling sessions from the months of June 2025, July 2025, August 2025, September 2025, November 2025, and February 2026.
Client #3 was admitted on August 27, 2025 and discharged on January 15, 2026. A comprehensive treatment and rehabilitation plan update, documented in the client record on September 26, 2025, indicated that the client was to receive one individual counseling session and one group counseling session per month; however, there were no individual counseling sessions documented for the months October 2025, November 2025 and December 2025. Additionally, there were no group sessions documented in the record for the month of November 2025.
Client #4 was admitted on May 5, 2025 and was discharged September 3, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on June 2, 2025, indicated that the client was to receive one individual counseling session per month; however, there were no individual counseling sessions in the month of August 2025.
Client #5 was admitted on January 28, 2025 and was discharged on February 4, 2026. A comprehensive treatment and rehabilitation plan update, documented in the client record on March 25, 2025, indicated that the client was to receive one individual counseling session and one group counseling session per month; however, there were no individual counseling sessions documented for the months August 2025, September 2025 and October 2025. Additionally, there were no group sessions documented in the record for the month of June 2025, October 2025, December 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Effective immediately, and to be fully implemented within 7 business days, all active patient records will be reviewed to verify that counseling services align with treatment plans, and any missed services will be addressed through documentation in the respective Pt.'s record, updated scheduling and clinical review. The clinical supervisor will review daily checklists providing guidance to counselors on documenting and reschedule missed sessions in real time. Responsibility for reviews will be shared by the Clinic Director and Clinical Supervisor, with counselors responsible for delivering and documenting services as outlined in the treatment plan and the Clinical Supervisor responsible for oversight of counselor caseloads and service delivery. The Clinic Director and Clinical Supervisor will monitor compliance through weekly audits of a minimum a monthly caseload review report comparing required versus completed sessions, with findings reviewed in supervision and leadership meetings. Ongoing compliance will be tracked monthly with a goal of 100% adherence to treatment plan requirements, and any deficiencies will be addressed immediately through staff retraining, supervision, and progressive accountability measures to ensure sustained compliance with regulatory requirements. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records and administrative information, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record was submitted and approved by the Department for the March 7, 2025, March 29, 2024, and March 31, 2023, annual licensing inspections. Obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record, was again found to be a deficiency in the March 4, 2026 through March 5, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the facility will implement enhanced oversight and monitoring processes to ensure that all approved plans of correction are fully implemented and consistently followed throughout the current licensing period.
Clear responsibility for implementation of all plans of correction is assigned to program leadership, including the Clinic Director and Clinical Supervisor, with involvement from administrative and clinical staff as applicable. Approved corrective actions are incorporated into daily operational workflows, including admission procedures, documentation requirements, and supervisory review processes, to ensure requirements are addressed at the point of service delivery.
The facility utilizes system‑based controls within the Electronic Health Record (EHR), including required fields and hard‑hold functionality where appropriate, to support consistent implementation of corrective actions and prevent noncompliant actions from occurring. Required elements tied to plans of correction are embedded into admission checklists and routine documentation reviews.
Ongoing monitoring occurs through daily review of applicable activities, weekly supervision discussions, and monthly tracking to confirm continued adherence to corrective actions. Compliance with approved plans of correction is reviewed during supervision and leadership meetings to identify trends, gaps, or areas requiring additional oversight.
Any identified deficiencies are addressed promptly through corrective action, staff retraining, and supervisory follow‑up. Leadership maintains accountability for ensuring corrective actions are completed timely and sustained throughout the licensing period. These monitoring and enforcement practices are maintained continuously to ensure ongoing compliance with regulatory requirements and adherence to approved plans of correction. |