INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2, 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 three 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 26 hours per week devoted to their 29 clients on their caseload.
The FTE counselor ' s caseload calculation is as follows: 26/40 = .65(FTE); 29/.65 = 44.61, which equals to a client/counselor ratio of 44:1.
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 31, 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. |
709.28 (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 an informed and voluntary consent from the client prior to the disclosure of information in one of seven client records.
Client #2 was admitted July 10, 2025 and discharged February 13, 2026. Confirmed disclosures were made to a government agency on September 15, November 7, November 10, December 10, December 31, and February 13 without a valid release of information.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
3. In response to citation #3 referencing 709.28 c Confidentiality. The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Treatment and Rehabilitation Services, Program Director and Clinical Supervisor reviewed the chart referencing Clients #2. Updates were made to the intake process and checklist used by intake workers and counselors to ensure that these consents were completed fully and in accordance with confidentiality standards reviewed with all team members at staffing's on both 3/21/2026 and 3/28/2026. Monthly charts audits have begun in March 2026 and will include ongoing reviews for presence of full and correct client consents. This facility is in full compliance with this standard as of 3/28/2026 |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included a date, event, or condition upon which the consent will expire in seven of seven records reviewed.
Client #1 was admitted October 23, 2025 and discharged November 24, 2025. A release was signed to six entities on October 23, 2025 which failed to include a date, event, or condition upon which the consent will expire.
Client #2 was admitted July 10, 2025 and discharged February 13, 2026. A release was signed to six entities on July 10, 2025 which failed to include a date, event, or condition upon which the consent will expire. Another release was signed to two entities on July 16, 2025 which failed to include a date, event, or condition upon which the consent will expire.
Client #3 was admitted August 18, 2025 and still a current client. A release was signed to seven entities on August 18, 2025 which failed to include a date, event, or condition upon which the consent will expire.
Client #4 was admitted August 11, 2025 and still a current client. A release was signed to four entities on August 11, 2025 which failed to include a date, event, or condition upon which the consent will expire.
Client #5 was admitted September 22, 2025 and still a current client. A release was signed to five entities on September 22, 2025 which failed to include a date, event, or condition upon which the consent will expire. Another release was signed to a government agency on January 28, 2026 which failed to include a date, event, or condition upon which the consent will expire.
Client #6 was admitted October 1, 2025 and still a current client. A release was signed to six entities on October 1, 2025 which failed to include a date, event, or condition upon which the consent will expire.
Client #7 was admitted October 30, 2025 and still a current client. A release was signed to six entities on October 30, 2025 which failed to include a date, event, or condition upon which the consent will expire. Another release was signed to an agency on November 13, 2025 which failed to include a date, event, or condition upon which the consent will expire
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
4. In response to citation #4 referencing 709.28 c (6) Confidentiality. 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: Date, event or condition upon which the consent will expire. Program Director and Clinical Supervisor reviewed the chart referencing Clients #1-7. Updates were made to the intake process and checklist used by intake workers and counselors to ensure that these consents were completed fully and in accordance with confidentiality standards reviewed and identified via the DDAP Licensing representative. The consents included an additional drop-down ox to identify the specific date, event or condition upon which that specific consent will expired. These changes were then reviewed with all team members at staffing's on both 3/21/2026 and 3/28/2026, in conjunction with the POC for citation #3 listed above. Monthly chart audits have begun in March 2026 and will include ingoing reviews for presence of full and correct client consents. This facility is in full compliance with this standard as of 3/28/2026. |
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 five of seven records.
Client #1 was admitted October 23, 2025 and discharged November 24, 2025. Treatment plan was developed on October 29, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #2 was admitted July 10, 2025 and discharged February 13, 2026. Treatment plan was developed on July 16, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #3 was admitted August 18, 2025 and still a current client. Treatment plan was developed on September 4, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #6 was admitted October 1, 2025 and still a current client. Treatment plan was developed on October 15, 2025 and did not include type and frequency of treatment and rehabilitation services.
Client #7 was admitted October 30, 2025 and still a current client. Treatment plan was developed on November 13, 2025 and did not include type and frequency of treatment and rehabilitation services.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
5. In response to the citation #5 referencing 709.92 (a) (2) Treatment and rehabilitation services. An individual treatment and rehabilitative services shall be developed with a client. This plan shall include, but not be limited, written documentation of: type and frequency of treatment and rehabilitation services. Program Director and Clinical Supervisor reviewed the chart referencing Clients #1,2,3,6 and 7. Program Director worked with EMR and compliance department to make additions to include mandatory fields in the treatment plan form in the EMR that document that the specific type and frequency of services reflective of what each individual client is receiving, and as part of each level of care (IOP/OP). Once these changes were completed in the EMR, the new treatment plan forms were made active and then reviewed with all team members at staffing on 3/28/2026. Monthly chart audits have begun in March 2026 and will include ongoing reviews for accurate completion of type and frequency of services noted in each treatment plan. 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 six of seven records.
Client #2 was admitted July 10, 2025 and discharged February 13, 2026. A treatment plan was completed on August 20, 2025 and an update was due by October 19, 2025 but not completed until October 30, 2025. Another update was due by December 29, 2025 but not completed until February 13, 2026.
Client #3 was admitted August 18, 2025 and still a current client. A treatment plan was completed on September 4, 2025 and an update was due by November 3, 2025 but not completed until November 11, 2025. Another treatment plan was due by January 10, 2026 but not completed until February 3, 2026.
Client #4 was admitted August 11, 2025 and still a current client. A treatment plan was completed August 26, 2025 and an update was due by October 25, 2025 but not completed until December 1, 2025. Another update was due by January 30, 2026 but not completed until February 11, 2026.
Client #5 was admitted September 22, 2025 and still a current client. A treatment plan was completed November 26, 2025 and an update was due by January 25, 2026 but not completed until February 11, 2026.
Client #6 was admitted October 1, 2025 and still a current client. A treatment plan was completed November 19, 2025 and an update was due by January 18, 2026 but not completed until January 21, 2026.
Client #7 was admitted October 30, 2025 and still a current client. A treatment plan was completed November 13, 2025 and an update was due by January 12, 2026 but not completed at the time of the inspection.
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. |