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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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
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 one of one records.
Client #1 admitted September 25, 2024 and still a current client. A treatment plan was completed on July 1, 2025 and an update was due by August 30, 2025 but not completed until October 22, 2025. Another update was due by December 21, 2025 but not completed until January 17, 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 4, 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. |