INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2-3, 2026 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on review of The Staffing Requirements Facility Summary Report, the FTE counselor caseload in the outpatient program exceeded 35 active clients for one of one staff.
Staff #3 was hired as a counselor on December 4, 2023 and still in the position at the time of the inspection. Staff #3 was reported to have 3 hours per week devoted to their 3 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 3/40 = .075(FTE); 3/.075 = 40 which equals to a client/counselor ratio of 40:1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by the facilities hours of operation 40. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. In response to the citation 1, referencing 714.12, Full-time equivalent (FTE) maximum client/staff and client/counselor ratio. Program Director and Clinical Supervisor reviewed the caseload for each counselor and re-assigned clients from the part-time counselor who was over 35/1 active caseload. On 3/21/2026 at supervision meeting, Program director reviewed the 35/1 ratio with the counselor and intake team members to ensure the understood how that ratio applies to a part-time counselor. Each client was case consulted at staffing on 3/28/2026, and supervisors will calculate the caseload sizes for each counselor and review at weekly staffing to prevent further instances of exceeding ratio. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative information, the facility failed to ensure the project director annually prepared, updated, and signed the written manual delineating the project policies and procedures for the year 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
2. In response to the citation #2, referencing 709.23. Project Director: shall prepare, annually update and signs a written manual delineating project policies and procedures. On 3/28/2026. The Project Director was able to prepare, update and sign a written plan delineating the project policies and procedures for the year 2025. The project director will work each year with our compliance department and the completed documented for submission to DDAP for each monitoring visit. This facility is in full compliance with this standard as of 3/28/2026. |
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 a review of client records, the facility failed to update individual treatment plans every sixty days in two of two records.
Client #1 admitted January 23, 2025 and still a current client. A treatment plan was completed on June 30, 2025 and an update was due by August 29, 2025 but not completed until November 13, 2025. Another update was due by January 12, 2026 but not completed until February 18, 2026.
Client #2 admitted May 21, 2025 and still a current client. A treatment plan was completed on May 21, 2025 and an update was due by July 20, 2025 but not completed until August 6, 2025. Another treatment plan was due by October 5, 2025 but not completed until October 22, 2025. The next update was due by December 21, 2025 but not completed until January 3, 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
6. In response to the citation #6, referencing 709.92 (b) Treatment and Rehabilitation Services. Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days. Program Director and Clinical Supervisor reviewed the charts which were noted by the Licensing Representative as a being deficient in that the facility failed to document treatment plan updates every 60 days. Program Director and Clinical Supervisor identified internal monitoring tools available to ensure that staff are aware of the standards for completion of treatment plan updates occurring at least every 60 days. All staff have access to reports contained within our EMR Avatar to ensure timely documentation of treatment plan updates. Program Director and Clinical Supervisor met with clinical team at the weekly staff meeting 3/21/2026 and reviewed citation, standards and timeframes for treatment plan updates and provide refresher training on how to access reports via EMR. Weekly staff meetings will continue to include timeframes specified for case consultation and review of treatment progress and plan updates. Individual staff supervisions, which occur at minimum of once per month, will include review of EMR reports to ensure consistent and timely completion of treatment plan updates. This facility is in full compliance with this standard as of 3/28/2026. |
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 a review of client records, the facility failed to document case consultations in one of two records reviewed.
The facility's policy and procedure manual states a case consultation must be completed every 90 days.
Client #1 admitted January 23, 2025 and still a current client. A case consultation was due by August 20, 2025 but not completed until February 18, 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In response to the citation identified in regards to having case consults completed on each client every 90 days, Program Director and Clinical Supervisor worked with EMR team and Compliance to ensure that reports track when case consults are due, and that counselors have access to this information. This was then relayed to staff at weekly staffing on 3/28, and will continue to be reviewed at weekly staff meetings, individual supervisions and as part of monthly chart audits. |