INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on May 1, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Armada Recovery PA - dba Blueview Recovery 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from December 2025 - April 2026, the facility failed to prepare alternative exit routes to be used during fire drills. All drills used the main door to exit.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire drills are completed on a monthly basis, therefore moving forward, every other month alternatively, the Clinical Director, Owner, Facilities Director, Clinical and or Administrative staff will complete fire drills using the side/ back door to exit out of the office suite. An additional meeting point will be used in the back of the building when the alternative route is utilized every other month. Starting from June, the facility staff will utilize the side/back door to exit and either go out through the main door to the picnic area or go to the back of the building and walk to the far left of the building away from the building. Both the main and side entrances will be utilized alternatively every other month to ensure safety and compliance. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of five applicable records reviewed.
Client #8 was admitted on December 29, 2025 and discharged on March 3, 2026. A comprehensive treatment plan was completed on January 14, 2026 and an update was due no later than February 14, 2026; however, none was completed.
Client #10 was admitted on January 5, 2026 and discharged on March 19, 2026. A comprehensive treatment plan was completed on January 13, 2026 and an update was due no later than February 13, 2026; however, it was completed on February 18, 2026.
This is a repeat citation from the October 23-24, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During weekly individual supervision and all staff meetings, Clinical Director will review caseloads ensure treatment plan updates are completed for clients within their due dates. A monthly email indicating due dates for treatment plans will be sent to all clinicians. Clinical Director will complete chart audits on a monthly basis to ensure that IOP treatment plan updates are completed within 60 days of when the master treatment plan was completed. Clinicians who do not adhere to the clinical requirements will be written up and reprimanded for not following the state requirements for the program. |
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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of four applicable records.
Client #1 was admitted on February 18, 2026 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 18, 2026 and an update was due no later than April 18, 2026; however, none was completed.
Client #3 was admitted on December 19, 2025 and discharged on April 27, 2026. A comprehensive treatment plan was completed on February 10, 2026 and an update was due no later than April 10, 2026; however, none was completed.
Client #4 was admitted on January 15, 2026 and discharged on April 14, 2026. A treatment plan update was completed on February 10, 2026 and an update was due no later than April 10, 2026; however, none was completed.
Client #6 was admitted on December 18, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was completed on February 10, 2026 and an update was due on April 10, 2026; however, none was completed.
This is a repeat citation from the September 11, 2024 and October 23-24, 2025 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During weekly individual supervision and all staff meeting, Clinical Director will review caseloads ensure treatment plan updates are completed for clients within their due dates. A monthly email indicating due dates for treatment plans will be sent to all clinicians. Clinical Director will complete chart audits on a monthly basis to ensure that PHP treatment plans are completed within 30 days and IOP treatment plans are completed within 60 days of when the master treatment plan was completed. Continued reminders will be provided to Clinicians to ensure treatment plans are completed within 30 days. Clinicians who repeatedly refuse to complete treatment plans and updates within time frame will be reprimanded and written up until they adhere to the treatment requirements of the state for the program |
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.
Plans of correction for outpatient treatment plan updates were submitted and approved by the Department for October 23-24, 2025 and September 11, 2024 annual licensing inspections. Outpatient treatment plan updates were again found to be a deficiency in the May 1, 2026 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During weekly individual supervision and all staff meetings, Clinical Director will review caseloads ensure treatment plan updates are completed for clients within their due dates. A monthly email indicating due dates for treatment plans will be sent to all clinicians. Clinical Director will complete chart audits on a monthly basis to ensure that Outpatient treatment plan updates are completed within 60 days of when the master treatment plan was completed. Clinicians who do not adhere to the clinical requirements will be written up and reprimanded for not following the state requirements for the program. |