INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 25 & 26, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Arkview Recovery Center 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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709.28 (c) (2) 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:
(2) Specific information disclosed.
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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 for the disclosure of information contained in the client record that included the specific information to be disclosed in one out of twenty-five applicable records reviewed.
Client #27 was admitted to the outpatient level of care on June 29, 2026, and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to an emergency contact signed by the client on June 18, 2026, that did not identify the specific information to be released.
This is a repeat citation from the June 9, 2022, June 5, 2023, August 6, 2024, and October 2, 2025, annual licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will retrain all applicable staff on the requirements of § 709.28(c)(2), with specific emphasis on ensuring that all informed and voluntary consents clearly identify the specific information authorized for disclosure.
Training will include review of the regulatory requirement, proper completion of releases of information, and examples of compliant and noncompliant documentation. Staff will be instructed to review each consent for completeness prior to its use.
Following training, the Clinical Director/designee will conduct routine audits of client records to verify that releases of information contain all required elements, including identification of the specific information to be disclosed.
In addition to facility-level monitoring, this requirement will be incorporated into the corporate compliance auditing process. Corporate leadership will utilize AI-supported chart auditing to assist with identifying incomplete or potentially noncompliant releases of information. Audit findings and trends will be reviewed through the organization's Quality Assurance process to ensure continued and sustained compliance.
Target for compliance: 100% of audited informed and voluntary consents will identify the specific information authorized for disclosure.
In regards to client #27, the client never returned to programming after Aug 6. As such, the agency was not able to have the client sign a new ROI. |
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 the review of client records, the facility failed to document case consultations at least one time prior to discharge, per the facility's policy, in two out six applicable records reviewed.
Client #28 was admitted to the outpatient level of care on December 29, 2025, and discharged on January 16, 2026. A case consultation was due no later January 16, 2026; however, there was no documentation that one was completed.
Client #31 was admitted to the outpatient level of care on June 5, 2026, and discharged on July 10, 22026. A case consultation was due no later than July 10, 2026; however, there was no documentation that one was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will revise its Case Consultation Policy to clarify the required frequency and documentation of case consultations. The revised policy will state: "Case Consultations ? to be completed and documented as they occur. Each patient will receive, at minimum, one case consultation during their stay, unless the client leaves treatment unexpectedly before a consultation occurs."
Target for compliance: 100% of applicable client records will contain at least one documented case consultation during the client's treatment episode, except when an unplanned discharge occurs before a case consultation is completed.
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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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining an informed and voluntary consent from the client for the disclosure of information in the client record to include specific information to be disclosed was submitted and approved by the Department for the June 9, 2022, June 5, 2023, August 6, 2024, and October 2, 2025, annual licensing inspections. Obtaining an informed and voluntary consent from the client for the disclosure of information in the client record to include specific information to be disclosed was again found to be a deficiency in August 25 & 26, 2026, licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The organization recognizes that previously approved Plans of Correction did not result in sustained compliance. To address this finding, Arkview will implement a centralized corporate oversight process for the implementation, monitoring, and continued effectiveness of Plans of Correction.
Upon approval, each Plan of Correction will be incorporated into the organization's corporate compliance auditing process. Corporate leadership will monitor compliance through regularly scheduled audits, including the use of AI-supported chart auditing to identify missing, incomplete, or potentially noncompliant documentation associated with cited standards.
Results of these audits will be reviewed by corporate leadership and incorporated into the organization's Quality Assurance process. Any identified noncompliance will require documented follow-up, which may include staff retraining, supervisory intervention, corrective action, modification of the applicable process or policy, and increased auditing.
The Corporate Quality/Compliance team will be responsible for oversight of this process, with facility leadership responsible for implementing required corrective actions and responding to audit findings.
Target for compliance: 100% of approved Plans of Correction will be incorporated into the corporate compliance auditing process, with documented monitoring and follow-up to verify implementation and sustained compliance.
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