INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 19, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Armor Health of Erie PA & D&A, PLLC 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to develop a written individual training plan for each employee in one of four records.
Staff #1 was hired as project director October 20, 2025. There was no documentation of an individual training plan for the 2026 training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
2026 Individual Training Plan for Program Director was created and submitted to share point at the end of May. Program Director is responsible for completing training plan by December 2026. Program Director will ensure compliance with regulation. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document that clients were oriented to the project including disclosure of hours of operation during intake in seven of seven records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Supervisor, completed addition to the clinical Consent form 6/1/2026.
" Hours of Operation are Monday - Friday 8AM to 4PM"
Counselors are responsible to review with client at intake and capture client's signature. Lead counselor will review during chart audits to assure compliance. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document that clients were oriented to the project including disclosure of fee schedules during intake in seven of seven records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Supervisor, completed addition to the clinical consent form 6/1/2026.
" This program is funded by Erie County Office of Drug and Alcohol. Therefore, there are NO FEES associated with this program if you choose to participate.
Counselors are responsible to review with client at intake and capture client's signature. Lead counselor will review during chart audits to assure compliance. |
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 every 60 days in three of three applicable records.
Client #2 admitted November 20, 2025 and still a current client. A treatment plan was completed on January 13, 2026. The treatment plan update was due by March 14, 2026 but not completed until April 9, 2026.
Client #3 admitted January 27, 2026 and still a current client. A treatment plan was completed on March 13, 2026. The treatment plan update was due by May 12, 2026 but not completed at the time of inspection.
Client #4 admitted February 18, 2026 and still a current client. A treatment plan was completed on February 18, 2026. The treatment plan update was due by April 19, 2026 but not completed until April 20, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will utilize date calculation trackers to effectively manage and track treatment plan updates.
Lead counselor will complete chart audits on a quarterly basis to ensure treatment plan updates are completed on time. |
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 client records, the facility failed to document follow-up attempts in three of four applicable records.
The policy and procedure states that follow-up contact is attempted no later than 7 day post discharge.
There was no follow-up documented in the following client records.
Client #1 admitted November 19, 2025 and discharged January 6, 2026.
Client #5 admitted March 5. 2026 and discharged April 24, 2026.
Client #6 admitted March 9, 2026 and discharged May 5, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Supervisor amended "Aftercare and Discharge Planning" policy on 6/1/2026 to remove the 7 day follow up requirement.
Counselors were informed of updated policy change on 6/1/26. Program Supervisor will conduct quarterly chart review to ensure policy compliance. |