INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 2-3, 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 Lancaster, LP 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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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of the patient records, the facility failed to complete an initial drug-screening urinalysis for each prospective patient in one out of six applicable records.. Patient #7 was admitted on August 27, 2025 and was still active at the time of the inspection. No urinalysis was completed prior to dosing.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
10.3.25 ? DDAP auditor reeducated DON that ALL patients, even prisoners needed to comply with UDS regulations.
10.7.25 ? Arrangement was made with LCP to ensure guards were aware that patients need to complete UDS on admission. There will be a monthly follow up with LCP to ensure we do get a copy of UDS from the prison.
10.7.25 ? UDS report ran by ED and DON is to follow up., this will be a monthly report audited by ED expected to be completed by 12.31.25
10.14.25 Leadership meeting discussed regulation and steps to rectify.
10.22.25- Will educate all staff on regulation and POC which will be documented and held in the compliance binder . |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document that it notified a patient's previous facility of the patient's admission including the date of initial dose in one out of two applicable records. Patient #11was admitted on November 13, 2024 and was discharged on August 28, 2025.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
10.3.25- Education was done with DON.
10.10.25- A transfer report was created in KIPU to track patients and generate report
10.10.25- Teams chat created where all discharged patients are entered, to easily track
10.10.25- DON is inserting a copy of the fax sheet with acceptance and dosage to previous clinic, uploaded under disclosure log
10.10.25- ED is doing weekly audits of this to ensure ongoing compliance, which will be an ongoing part of monthly leadership meeting reviews until 12.31.25.
10.14.25- Leadership meeting discussed regulation and steps to rectify.
10.22.25- Will educate all staff on regulation and POC which will be documented and held in the compliance binder
Clinical Supervisors will include this audit in weekly audits. We will discuss any discrepancies during the monthly supervision meeting.
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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 a review of patient records, the facility failed to document an annual physical examination within the regulatory timeframe in one out of four appliable records.Patient #4 was admitted to on August 17, 2014 and was discharged on July 8, 2025. The annual physical examination was due no later than January 5, 2025; however, none was documented.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
10.3.25- Reeducation with DON and medical staff was completed.
10.9.25- Patient education- signs at dosing windows, check in station, and doors that daily dosing will be implemented until patients are compliant with their annual hp requirement.
10.7.25- DON and medical given directive that patients are to be scheduled one month prior to due annual date. If the patient has 28 days of take homes, they will be scheduled to meet two months in advance. If the appointment is missed, the patient will not receive the entire 28 take homes, however, will receive enough until they can come back for the rescheduled annual. As long as they successfully meet with the medical provider, they will be able to then resume the 28 day take home schedule.
10.7.25 ? Nursing is adding a note under nursing note if a patient reschedules, this will be document under medical note. Patients are aware they will be daily dosing until completion.
10.11.25- Audit to identify late annual hp. This audit to be completed by 10.31.25. Patients are being called to schedule within the next 3 weeks to bring them into compliance. Chart is documented as a part of the POC audit 10.3.25.
10.3.25- ED to run monthly audits, DON will flag and schedule patients according.
10.14.25- Leadership meeting discussed regulation and steps to rectify.
10.22.25- Will educate all staff on regulation and POC which will be documented and held in the compliance binder |
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 a review of patient records, the facility failed to document an annual clinical evaluation with all areas of regulation addressed within the regulatory timeframe in three out of four applicable records reviewed.Patient #4 was admitted on August 17, 2014 and was discharged on July 8, 2025. There was no documentation in the patient's record of an annual clinical evaluation being completed. Patient #9 was admitted on August 14, 2023 and discharged on April 22, 2025. There was no documentation in the patient 's record of an annual clinical evaluation being completed. Patient #10 was admitted on May 22, 2017 and was still active at the time of the inspection. The annual clinical evaluation was due on or before May 20, 2025; however, it was not completed until September 26, 2025. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the September 18, 2024 licensing inspection.
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Plan of Correction
10.7.25- Audit report ran and given to clinical supervisors to follow up with counselors to catch up on past due reviews, to be completed by 11.30.25.
10.11.25- ED followed up with clinical supervisors to get progress review.
10.17.25- ED will audit monthly for review during the leadership meetings, until 12.31.25. This will continue to be tracked and results will be trended quarterly.
10.14.25- Leadership meeting discussed regulations and steps to rectify.
10.22.25- Will educate all staff on regulation and POC which will be documented and held in the compliance binder
In addition to the quarterly peer review audit which included the annual clinical reviews, the clinical supervisor and/or executive director, will run a report monthly at minimum to determine which patients are in need of an annual clinical review for the following month, and will inform the counselors to ensure the clinical team is completing the annual clinical review in compliance with the regulation moving forward. Flags will be utilized as a reminder as to when these need to be completed and will include details including due dates. These flags will be set to appear at least 30 days before this review is required to be completed. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of patient records, the facility failed to document a complete psychosocial evaluation within the guidelines established by the facility's policy and procedure manual in two out of six applicable records reviewed. The facility's policy and procedure manual states the psychosocial evaluation must be completed within 14 days of admission.Patient#5 was admitted on July 31, 2025 and was still active at the time of the inspection. The psychosocial evaluation was due no later than August 14, 2025; however, it was not completed until August 21, 2025. Patient #7 was admitted on August 27, 2025 and was still active at the time of the inspection. The psychosocial evaluation was due no later than September 10, 2025; however, it was not completed until September 20, 2025. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
10.3.25- Educated clinical supervisors on the 14 days of admission.
10.14.25- Leadership meeting discussed regulation and steps to rectify.
10.22.25- Will educate all staff on regulation and POC which will be documented and held in the compliance binder
An audit is done monthly, ED to check and follow up with clinical supervisor /and or counselor to complete Biopsychosocial eval
The clinical supervisor will complete the monthly required admission and discharge audits as anticipated, at minimum weekly and in real time to ensure the biopsychosocial is completed within the time frame depicted in the policy. The Clinical supervisor will meet with the clinical staff bi-monthly for group supervision to review biopsychosocial completion, questions as well as other documentation needing additional training and review. The ED will meet with the clinical supervisor monthly to review audits completed, areas of deficiency, and plan of correction. ARS QA will also assist in monitoring the accuracy and timely completion of these audits |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of patient records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of five applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days following admission. Additionally, it must be completed with the patient.Patient #2 was admitted on December 6, 2024 and was discharged on August 29, 2025. A comprehensive treatment plan was completed on December 19, 2024; however, there was no documentation that it was completed with the patient.Patient #5 was admitted on July 31, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than August 30, 2025; however, it was not completed until September 30, 2025.Patient #11 was admitted on November 13, 2024 and discharged on August 28, 2025. A comprehensive treatment plan was due no later than December 12, 2024; however, none was completed.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Ongoing monthly audit, ED to audit the audit and follow up accordingly.
10.14.25- Leadership meeting discussed regulation and steps to rectify.
10.22.25- Will educate all staff on regulation and POC which will be documented and held in the compliance binder
Clinical supervisor audits all admission charts which includes the development and completion (all signatures present) of a comprehensive treatment plan within the first 30 days of admission. Clinical supervisor will ensure these audits are done weekly at minimum so timely follow up takes place. Clinical Supervisor will meet with Executive Director monthly to review any deficits which need additional follow up and potential corrective action. ARS QA specialist will also monitor accurate and timely completion of these audits. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to provide a complete patient record, which is to include aftercare information in two out of four applicable discharged records reviewed.Patient #4 was admitted on August 17, 2014 and was discharged on July 8, 2025. Patient #11 was admitted on November 13, 2024 and discharged on August 28, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and expectation of Transition/Aftercare Plans was recently updated within the organization. All patients are to have a preliminary aftercare/transition plan within the first 90 days of treatment which can then be updated if/when a person is preparing to transition out of treatment. In addition, the clinical supervisors will facilitate a review of this expectation in the next clinical supervision meeting. The Primary Counselor will ensure that all patients with a planned discharge receive an updated and complete aftercare plan prior to discharge, thoroughly addressing all required components. The Clinical Supervisor will conduct audits of all discharge charts within five business days following discharge to verify compliance and prevent recurrence of deficiencies. In addition the transition plan form will be added to the annual portion of the peer review audits which are done quarterly to further review and ensure all patients have one completed within 90 days of treatment. ARS QA specialist will also monitor the accuracy, completion and timeliness of these audits.
10.10.25- Teams chat created where all discharged patients are entered, to easily track
10.14.25- Leadership meeting discussed regulation and steps to rectify.
Discharge analysis will be tracked monthly by clinical supervisor.
10.22.25- Will educate all staff on regulation and POC which will be documented and held in the compliance binder |
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 four out of six applicable records reviewed. The facility's policy and procedures manual states that follow up must be completed 7 days following discharge.Patient #2 was admitted on December 6, 2024 and was discharged on August 29, 2025. A follow up was due no later than September 5, 2025; however, none was completed.Patient #8 was admitted on January 5, 2016 and was discharged on April 21, 2025. A follow up was due no later than April 28, 2025; however, none was completed.Patient #9 was admitted on August 14, 2023 and was discharged on April 22, 2025. A follow up was due no later than April 29, 2025; however, none was completed.Patient #11 was admitted on November 13, 2024 and was discharged on August 28, 2025. A follow up was due no later than September 4, 2025; however, none was completed.This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the September 18, 2024 licensing inspection.
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Plan of Correction
10.7.25- Discussed the compliance need with the intake coordinator who also does follow up calls. Instructed to document all attempts made.
10.10.25- Teams chat created where all discharged patients are entered, to easily track
10.14.25- Leadership meeting discussed regulation and steps to rectify.
10.22.25- Will educate all staff on regulation and POC which will be documented and held in the compliance binder
This will be audited in monthly discharge audits by the clinical supervisor. Each month, the ED and clinical supervisor will meet to review deficiencies and appropriate ways to address these. |