INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2026, 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document each counselor met the education qualifications for the position in one of six applicable records.Employee #9, who was hired as a counselor on February 2, 2026, did not meet the educational requirements to be a counselor. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Counselor qualifications will be reviewed by the Clinical Director and Executive Director to assure that 704.7 is followed for the appropriate education including degree and field of study, along with the appropriate amount of experience. In the event of any questions, a DDAP licensing specialist will be contacted. |
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 a review of inpatient client records, the facility failed to document follow-up information in one of three applicable records.The facility's policy and procedures state that a follow-up phone call is to be completed 7 days, 30 days, 60 days, and 6 months after discharge.Client #14 was admitted to the inpatient level of care on May 16, 2025, and discharged on June 13, 2025. There was no follow-up information documented.This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the March 19, 2025 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 within 30 days after discharge from the facility. Additionally, the Clinical Director will run a monthly discharge report to compare to the existing follow-up call tracker spreadsheet, which is used 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 timeframe. This policy will be reviewed by the Board of Directors on April 27, 2026, and reviewed in the monthly staff Integration Meeting on April 14, 2026. |