INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Arc Manor 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project and facility director met the qualifications of the position at the time of hire in one of one applicable personnel records reviewed.
Staff #1 was hired as Chief Financial Officer on March 17, 2015 and transitioned to Project and Facility Director on June 11, 2024. Staff #1 did not meet the experience requirements to be the Project and Facility Director.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Personnel Committee of the Board of Directors will review all qualifications of the Project and Facility Director when hiring for the position. Specifically, the regulations will be reviewed along with the individual's resume, degree earned, years of experience to include supervision of others, direct service and program planning. In the event that there is any uncertainty as to whether the individual meets all qualifications, DDAP Licensing will be contacted to request a review of the documents. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in five of seven applicable records.
The facility policy and procedure manual indicate a case consultation to occur at intake, then weekly thereafter.
Client #1 was admitted to inpatient on February 26, 2025 and still active at the time of the inspection. A case consultation was due to occur no later than March 7, 2025, however this was not completed at the time of the inspection.
Client #2 was admitted to inpatient on March 7, 2025 and still active at the time of the inspection. A case consultation was due to occur no later than March 14, 2025, however this was not completed at the time of the inspection.
Client #3 was admitted to inpatient on February 12, 2025 and still active at the time of the inspection. A case consultation was due to occur no later than February 19, 2025, however this was not completed until February 21, 2025.
A case consultation was due to occur no later than March 7, 2025, however this was not completed until March 14, 2025.
Client #5 was admitted to inpatient on November 20, 2024 and discharged January 14, 2025. A case consultation was due to occur no later than November 7, 2024 however this was not completed until January 13, 2025.
Client #7 was admitted to inpatient on August 21, 2024 and discharged October 2, 2024. A case consultation was due to occur no later than August 28, 2024 however this was not completed until September 13, 2024.
A case consultation was due to occur no later than September 27, 2024 however this was not completed until October 2, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The agency has updated policy 2.F.1 to revise the frequency of documented case consultations. The revision allows for case consultations to be documented in the EHR whenever a patient is discussed during supervision, clinical staff meetings, or any other instance where the case is discussed with clinical or medical staff, or when clinically necessary. Supervisors will remind clinical staff to complete the case consultations after each supervision, staff meeting or any other time a case is discussed. Supervisor will review and sign off on each case consultation to ensure that case consultations are completed in compliance with the policy. Clinical Director reviewed the updated policy with clinicians during the clinical staff meeting on March 20th, 2025. This policy was approved by the Board of Directors on March 24, 2025. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in two of four records.
The policy and procedure manual indicates follow-up contact must be made at thirty days and six months after discharge.
Client #5 was admitted to inpatient on November 20, 2024 and discharged January 14, 2025. The thirty day follow-up contact was due to be completed no later than February 14, 2025 however, this was not completed until February 18, 2025.
Client #7 was admitted to inpatient on August 21, 2024 and discharged October 2, 2024. The thirty day follow-up contact was due to be completed no later than November 2, 2024 however, this was not completed until November 21, 2024.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the March 14, 2024 annual licensing inspection.
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Plan of Correction
The agency has updated policy 2.B.4.d to revise the timeline for follow-up calls. The revision requires follow-up calls to be completed at seven days (residential only), thirty days, sixty days (residential only), and six months after discharge from an ARC episode of care. A grace period of 10 business days will be allowed for all follow-up call timeframes. Additionally, a follow-up call tracker spreadsheet has been be created to document each client's discharge date and the corresponding follow-up call dates. The Clinical Director and the Financial Director will monitor this tracker to ensure that calls are completed within the required timeframes. This policy was approved by the Board of Directors on March 24, 2025, and reviewed in the monthly Integration Meeting on 4/8/2025. The administrative staff, supervised by the Financial Director, is currently responsible for making follow-up calls. The Financial Director reviewed the revised policy and procedures with administrative staff on April 10, 2025. |
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 applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in three of six applicable records.
Client #9 was admitted to outpatient on June 20, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on December 2, 2024. A treatment and rehabilitation plan update was due no later than February 2, 2025, but was not completed until February 10, 2025.
Client #10 was transferred from inpatient to outpatient on May 6, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on September 9, 2024. A treatment and rehabilitation plan update was due no later than November 9, 2024, but was not completed until November 11, 2024.
A treatment and rehabilitation plan update was completed on November 11, 2024. A treatment and rehabilitation plan update was due no later than January 11, 2025, but was not completed until January 14, 2025.A treatment and rehabilitation plan update was completed on January 14, 2025. A treatment and rehabilitation plan update was due no later than March 14, 2025, but was not completed until March 19, 2025.
Client #12 was admitted to outpatient on August 9, 2024 and was discharged on January 24, 2025. A treatment and rehabilitation plan update was completed on September 23, 2024. A treatment and rehabilitation plan update was due no later than November 23, 2024, but was not completed until January 24, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director reviewed the treatment plan policy with counselors, discussing the timeline for treatment plan updates and when signatures are necessary, in the clinical staff meeting on March 20th, 2025. Clinical staff was reminded of the notice in their alerts for treatment plan updates and the treatment plan expiration notice on a client's EHR. Clinical Director and supervisors will monitor upcoming treatment plan expiration dates and send reminders to clinicians as applicable. |
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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in five of seven applicable records. The facility policy and procedure manual indicate a case consultation to occur every sixty days.
Client #8 was admitted to outpatient on October 7, 2024 and was still active at the time of the inspection. A case consultation was due to occur no later than January 12, 2025, however this was not completed at the time of the inspection.
Client #9 was admitted to outpatient on June 20, 2024 and was still active at the time of the inspection. A case consultation was due to occur no later than September 16, 2024, however this was not completed at the time of the inspection.
Client #10 was transferred from inpatient to outpatient on May 6, 2024 and was still active at the time of the inspection. A case consultation was due to occur no later than October 7, 2024, however this was not completed at the time of the inspection.
Client #12 was admitted to outpatient on August 9, 2024 and was discharged on January 24, 2025. A case consultation was due to occur no later than October 6, 2024 however this was not completed until January 24, 2025.
Client #13 was admitted to outpatient on September 24, 2024 and was discharged on December 2, 2024. A case consultation was due to occur no later than November 24, 2024 however this was not completed until December 2, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The agency has updated policy 2.F.1 to revise the frequency of documented case consultations. The revision allows for case consultations to be documented in the EHR whenever a patient is discussed during supervision, clinical staff meetings, or any other instance where the case is discussed with clinical or medical staff, or when clinically necessary. Supervisors will remind clinical staff to complete the case consultations after each supervision, staff meeting or any other time a case is discussed. Supervisor will review and sign off on each case consultation to ensure that case consultations are completed in compliance with the policy. Clinical Director reviewed the updated policy with clinicians during the clinical staff meeting on March 20th, 2025. This policy was approved by the Board of Directors on March 24, 2025. |
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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in two of three records. The policy and procedure manual indicates follow-up contact must be made at thirty days and six months after discharge.
Client #13 was admitted to outpatient on September 24, 2024 and was discharged on December 2, 2024. The thirty day follow-up contact was due to be completed no later than January 2, 2025 however, this was not completed until January 22, 2025.
Client #14 was admitted to outpatient on July 31, 2024 and was discharged on October 2, 2024. The thirty day follow-up contact was due to be completed no later than November 2, 2024 however, this was not completed until November 21, 2024.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the March 14, 2024 annual licensing inspection.
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Plan of Correction
The agency has updated policy 2.B.4.d to revise the timeline for follow-up calls. The revision requires follow-up calls to be completed at seven days (residential only), thirty days, sixty days (residential only), and six months after discharge from an ARC episode of care. A grace period of 10 business days will be allowed for all follow-up call timeframes. Additionally, a follow-up call tracker spreadsheet has been be created to document each client's discharge date and the corresponding follow-up call dates. The Clinical Director and the Financial Director will monitor this tracker to ensure that calls are completed within the required timeframes. This policy was approved by the Board of Directors on March 24, 2025, and reviewed in the monthly Integration Meeting on 4/8/2025. The administrative staff, supervised by the Financial Director, is currently responsible for making follow-up calls. The Financial Director reviewed the revised policy and procedures with administrative staff on April 10, 2025. |