INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 9-10, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ARS of Pennsylvania LLC 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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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. Employee #6 was hired on September 3, 2025 as a counselor and was still in the position as of the date of the inspection. The training was completed on September 18, 2025.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will conduct a training with Clinical Supervisor on 10/27/25 to review 7-day requirement. As of 10/28/25 the Clinical Supervisor will complete internal Health & Safety Training during the employee's first 7 days of employment. Executive Director will complete audit on new hire employment records within 7 days of hire to ensure all needed items are completed. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients. During the week of June 29-July 5, 2025, the patient census was 352. The facility was required to provide at least 35.2 physician hours. It provided 34.5 hours.During the week of September 21-27, 2025, the patient census was 362. The facility was required to provide at least 36.2 physician hours. It provided 31.5 hours.During the week of September 28-October 4, 2025, the patient census was 361. The facility was required to provide at least 36.1 physician hours. It provided 24 hours.This finding was reviewed with facility staff during the licensing inspection. This is a repeat from the September 11, 2023 and October 1, 2024 licensing inspections.
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Plan of Correction
Executive Director has implemented tracking sheet on 10/27/25 to track and review census weekly and compare to medical hours to ensure on-site hours match weekly census. Executive Director will verify appropriate coverage when medical staff are out of the office to fulfill required hours. Provider will provide a minimum of 30 days notice for any scheduled time off to allow for adequate time to secure coverage. Executive Director will submit tracking sheet to Director of Operations weekly to oversee tracking and implementation. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of physician time sheets, the facility failed to provide the required number of hours onsite for the physician based on the census. The facility has been granted an exception request which permits the physician to provide one-fifth of the required hours with a certified registered nurse practitioner or physician's assistant providing the remaining four-fifths of the required hours. During the week of September 21-27, 2025, the patient census was 362. The physician was required to provide one-fifth of the 36.2, which equals to 7.24 hours. The physician did not provide any hours that week. This finding was reviewed with facility staff during the licensing inspection. This is a repeat from the October 1, 2024 licensing inspection.
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Plan of Correction
Executive Director has implemented tracking sheet on 10/27/25 to track and review census weekly and compare to medical hours to ensure on-site hours match weekly census. Executive Director will verify appropriate coverage when medical staff are out of the office to fulfill required hours. Provider will provide a minimum of 30 days notice for any scheduled time off to allow for adequate time to secure coverage. Executive Director will submit tracking sheet to Director of Operations weekly to oversee tracking and implementation. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on the observation of medication administration, the facility failed to properly verify the correct identity of a patient prior to administration of an agent. The facility's policy and procedures manual states "each patient must remove their hat, hood, and sunglasses at the dosing window". There were five observed occurrences where the patient was not asked to remove their hat, hood, or sunglasses prior to dosing. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Nursing will conduct a training on 11/3/25 with all nursing staff on proper protocol for patient identification. Director of Nursing will shadow the dosing area at least 2 hours per week for the next 30 days to ensure patient identification protocols are followed. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician within the regulatory timeframe in two out of seven applicable records reviewed.Patient #4 was admitted on April 12, 2017 and was discharged on June 23, 2025. An annual physical was completed on March 19, 2024. An annual physical was due no later than March 19, 2025; however, it was not completed until April 15, 2025.Patient #5 was admitted on February 23, 2022 and was still active at the time of the inspection. An annual physical was completed on April 26, 2024. An annual physical was due no later than April 26, 2025; however, it was not completed until May 27, 2025.These findings were reviewed with facility staff during the licensing inspection. This is a repeat from the October 1, 2024 licensing inspection.
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Plan of Correction
The Director of Nursing will generate a monthly report of all current patients to identify those who are due for their annual or bi-annual physical examinations by a medical provider. This report will be shared with both the Executive Director and the designated medical provider. The DON and/or the medical provider will place a flag in the patient's chart 60 days prior to the month the annual physical examination is due. The medical provider will flag patients for annual appointments as shown on his schedule to ensure annual is completed before medication is continued. Director of Nursing will submit tracking sheet and list of completed appointments to Executive Directory monthly to ensure ongoing implementation. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual evaluation of each patient's status completed by the patient's counselor and reviewed, dated and signed by the medical director with all areas of regulation addressed, to include within the regulatory timeframe in five out of seven applicable records reviewed.Patient #4 was admitted on April 12, 2017 and was discharged on June 23, 2025. An annual clinical evaluation was completed on April 12, 2024 and the next evaluation was due no later than April 12, 2025; however, none was completed.Patient #5 was admitted on February 23, 2022 and was still active at the time of the inspection. An annual clinical evaluation was completed on February 23, 2024 and the next evaluation was due no later than February 23, 2025; however, none was completed.Patient #6 was admitted on March 17, 2017 and was discharged on October 7, 2025. An annual clinical evaluation was completed on March 17, 2024 and the next evaluation was due no later than March 17, 2025; however, none was completed.Patient #7 was admitted on March 30, 2023 and was still active at the time of the inspection. An annual clinical evaluation was completed on April 1, 2024 and the next evaluation was due no later than April 1, 2025; however, none was completed.Patient #8 was admitted on September 1, 2017 and was still active at the time of the inspection. An annual clinical evaluation was completed on September 1, 2024 and the next evaluation was due no later than September 1, 2025; however, none was completed.These findings were reviewed with facility staff during the licensing inspection.This is a repeat from the October 1, 2024 licensing inspection.
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Plan of Correction
The Clinical Supervisor will conduct a training on 11/3/25 with all counseling staff on the required timelines for all clinical documentation, including the patients annual clinical review and the required documentation for these reviews. An audit will be conducted of all current patients that have been a patient with the clinic for over a year to ensure that they have an annual clinical review in place. For those patients, who have been identified as not being compliant with an annual clinical review, their primary counselor will have until November 10, 2025 to complete an annual clinical review. Compliance with this process will be monitored through the quarterly peer audit review and reinforced during bi-weekly supervision sessions with the Clinical Supervisor and monthly group supervision with all members of the clinical team |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of patient records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of five applicable records reviewed. The facility's policy and procedures manual states that the follow-up must be completed seven days following discharge.Patient #4 was admitted on April 12, 2017 and was discharged on June 23, 2025. A follow up was due no later than June 30, 2025; however, none was completed. Patient #9 was admitted on October 9, 2017 and was discharged on January 31, 2025. A follow up was due no later than February 7, 2025; however, none was completed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will conduct a clinical training on November 5, 2025. This training will include a comprehensive review of discharge follow up protocols. The Primary Counselor will ensure that all patients they discharge receive a follow up call. The Clinical Supervisor will conduct audits of all discharge charts within seven business days following discharge to verify compliance. |
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 patient g records, the facility failed to comply with plans of correction that were approved by the Department. Plan of corrections for at least one hour of physician time a week were submitted and approved by the Department for the September 11, 2023 and October 1, 2024 annual licensing inspections. At least one hour of physician time a week was again found to be a deficiency in the October 10, 2025 licensing inspection.This finding was reviewed with facility staff during the licensing process
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Plan of Correction
Executive Director has implemented tracking sheet on 10/27/25 to track and review census weekly and compare to medical hours to ensure on-site hours match weekly census. Executive Director will verify appropriate coverage when medical staff are out of the office to fulfill required hours. Provider will provide a minimum of 30 days notice for any scheduled time off to allow for adequate time to secure coverage. Executive Director will submit tracking sheet to Director of Operations weekly to oversee tracking and implementation. Medical Director is always on call to assist with urgent matters. |