INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on June 4, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, ARS of Pennsylvania LLC, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 a review of client records and facility billing invoices, the facility failed to obtain a consent to release information form prior to releasing information in one of two records reviewed.
Client #1 was admitted on July 1, 2024, and discharged on April 16, 2026. There was no consent to release information form for the funding source. DDAP staff reviewed billing invoices and verified that the facility began billing the funder December 15, 2025.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
The Clinical Supervisor (CS) will retrain the clinical staff on release of information, including billing releases. Training will take place on 7/1/26. Office Manager will complete an audit of current patient records and will place a Kipu flag on patient chart if there are individuals in need of updated billing consents. Moving forward admission counselors will obtain patient signature on billing consent upon admission. CS will audit admission charts weekly to monitor. |
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 document treatment plan updates within the regulatory timeframe in one of two records reviewed.
Client #1 was admitted on July 1, 2024, and discharged on April 16, 2026.
A treatment plan update was completed on February 28, 2025, and the next treatment plan update was due no later than June 28, 2025. The next documented treatment plan was completed November 7, 2025.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
The Clinical Supervisor (CS) will retrain the clinical staff on Treatment Planning. Training will take place on 7/1/26. The CS will do a complete review of all existing client's charts and place a KIPU flag on patient chart in need of treatment plan update. The CS will review treatment plan due dates on a weekly basis to ensure that all patient's have a Treatment Plan update completed every 60/120 days. This will be monitored during the quarterly peer audit review process, as well as weekly by the CS during the quality assurance review process. |
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 facility failed to ensure that the clients received counseling services according to their individual treatment plan.
Client #1 was admitted on July 1, 2024, and discharged on April 16, 2026. A treatment plan dated November 7, 2025, indicated monthly individual sessions. There were no documented individual sessions for the months of December 2025 and January 2026.
Client #2 was admitted on August 5, 2024, and was still active at the time of the investigation. A treatment plan dated March 20, 2026, indicated monthly individual sessions. There were no documented individual sessions for the month of April 2026.
These findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
The Clinical Supervisor (CS) will retrain the clinical staff regarding counseling requirements. Training will take place on 7/1/26. The CS will review each counselor's engagement on a monthly basis and discuss how improvements can be made. The CS will train each counselor on how to monitor their own engagement through the course of the month by viewing their KIPU BI dashboard to see which patients are still in need of clinical services. No Show notes will be placed in the patient record if patient refuses to engage in scheduled appointment. |