INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 30-October 1, 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 Ephrata, LLC 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 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment. Employee #2 was hired on April 22, 2025 as the Clinical Supervisor and was still in the position as of the date of the inspection. The training was completed on May 20, 2025.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The employee that did not have the necessary training completed the required training by 10.13.2025. The Executive Director audited all other employee training files to ensure that they received the required training. As of 10.2.2025 all new staff that are employed in PA will be assigned Fire Safety Training on their first day of hire in the Relias training system. This will be due to be completed within the employee's first 7 days of employment to receive no citations in the future. The Executive Director will review every new employee's training record at the end of week one of orientation to ensure this training has been completed. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies. Employee #2 was hired on April 22, 2025 as a Clinical Supervisor and was still in the position as of the date of the inspection. The training was completed on June 5, 2025. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The employee that did not have the necessary training completed the required training by 10.13.2025. The Executive Director audited all other employee training files to ensure that they received the required training. As of 10.2.2025 all new staff that are employed in PA will be assigned Emergency Preparedness Training on their first day of hire in the Relias training system. This will be due to be completed within the employee's first 7 days of employment to receive no citations in the future. The Executive Director will review every new employee's training record at the end of week one of orientation to ensure this training has been completed |
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 five applicable records.Patient #9 was admitted on May 22, 2024 and was still active at the time of the inspection. The annual physical examination was due no later than May 22, 2025; however, it was not completed until May 27, 2025. This finding was reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 12, 2023 and September 16, 2024 licensing inspections.
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Plan of Correction
The Executive Director or the Medical Provider, in the absence of the ED, will generate a monthly report of all current patients to identify those who are due for their annual or bi-annual physical examinations by a medical provider. This report will be shared with both the Director of Nursing (DON) and the designated medical provider. The DON and/or the medical provider will place a flag in the patient's chart 60 days prior to the month the annual physical examination is due. The medical provider will ensure that the patient is scheduled and seen the month prior to the anniversary of the patient's last history and physical. The medical provider will ensure that the patient is seen for their physical examination prior to the administration of any medication. The Executive Director will continue to run this report on a monthly basis to monitor compliance and ensure that all required physical examinations are completed in a timely manner. In addition to placing a flag on the accounts, and running the report monthly, the DON and/or Medical Provider will ensure to schedule these exams with the patient at the time of the intake or annual history and physical and utilize the EMR scheduler. At minimum of one month prior to the scheduled history and physical, the patient will be reminded of this appointment. The patient will also be contacted by phone 72 hours in advance to confirm this appointment. This process is intended to prevent future citations and ensure adherence to regulatory requirements. |
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 the review of patient records, the facility failed to document an annual clinical evaluation with all areas of regulation addressed within the regulatory timeframe in four out of six applicable records reviewed.Patient #3 was admitted on August 7, 2024 and was still active at the time of the inspection. An annual clinical evaluation was due no later than August 7, 2025; however, it was not completed until September 9, 2025.Patient #4 was admitted on December 4, 2020 and was discharged on November 1, 2024. An annual clinical evaluation was due no later than August 7, 2025; however, none was completed.Patient #5 was admitted on June 29, 2023 and was still active at the time of the inspection. An annual clinical evaluation was completed on April 11, 2024 and the next annual clinical evaluation was due no later than April 11, 2025; however, it was not completed until June 3, 2025.Patient #7 was admitted on July 13, 2021 and was discharged October 31, 2024. No annual clinical evaluations have been completed. These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 12, 2023 and September 16, 2024 licensing inspections.
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Plan of Correction
The Clinical Supervisor conducted a training session with all counseling staff on the required timelines for all clinical documentation, including the patients annual clinical review and the required documentation for these reviews. This training was completed on October 8, 2025. An audit will be conducted of all current patients that have been a patient with the clinic for over a year to ensure that they have an annual clinical review in place. For those patients, who have been identified as not being compliant with an annual clinical review, their primary counselor will have until October 31, 2025 to complete an annual clinical review. Compliance with this process will be monitored through the quarterly peer audit review and reinforced during bi-weekly supervision sessions with the Clinical Supervisor and monthly group supervision with all members of the clinical team. 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. |
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 procedural manual in three out of five applicable records. The facility's policy and procedure manual states the psychosocial evaluation must be completed within fourteen days following admission,Patient #1 was admitted on May 16, 2025 and was still active at the time of the inspection. The psychosocial evaluation was completed on July 15, 2025.Patient #11 was admitted on May 14, 2025 and was still active at the time of the inspection. The psychosocial evaluation was completed on June 13, 2025.Patient #12 was admitted on October 30, 2024 and was still active at the time of the inspection. The psychosocial evaluation was completed on December 9, 2024.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 16, 2024 licensing inspection.
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Plan of Correction
The Executive Director conducted a training session for all counseling staff on the required timelines for clinical documentation. This training specifically addressed the completion of personal histories, including the ARS Biopsychosocial Assessment, which has now to be completed as part of the intake process on day one of the patient starting services with ARS of Ephrata. This training was held on October 9, 2025.
To ensure ongoing compliance, the clinical supervisor will complete the monthly required admission and discharge audits as anticipated, at minimum of weekly and in real time to ensure the biopsychosocial is completed within the time frame depicted in the policy.
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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 two 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.Patient #6 was admitted on July 22, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than August 22, 2025; however, it was not completed until August 25, 2025.Patient #11 was admitted on May 14, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than June 13, 2025; however, it was not completed until June 16, 2025. These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the September 16, 2024 licensing inspection.
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Plan of Correction
The Executive Director conducted a review with all counselors emphasizing the importance of obtaining signatures on treatment plans within three (3) days of their completion. Additionally, the supervisor will ensure counselors complete the treatment plan review in the designated "Treatment Plan Review" tab on Kipu. This training was reviewed by the Clinical Supervisor with all clinical staff on October 9, 2025.
To maintain compliance and quality, counselors' treatment plans will be monitored weekly through the overdue treatment plan report. The accuracy and completeness of treatment plans will be evaluated through quarterly peer review audits as well as monthly DQRAT audits, which assess both the completion status and the content quality of the treatment plans.
In addition, on October 2, 2025, the Executive Director submitted for an exemption waiver to have any patients who are compliant with treatment and have been in treatment for over 1 year to be able to move to 120 days treatment plan review schedule, which would reduce the risk for reoccurrence of this citation. This was also at the suggestion of the onsite auditor.
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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 patient records, the facility failed to document treatment plan updates within the regulatory timeframe in nine out of eleven records reviewed.Patient #1 was admitted on May 16, 2025 and was still active at the time of the inspection. A treatment plan update was completed on May 16, 2025 and an update was due no later than July 16, 2025; however, it was not completed until August 25, 2025. Patient #2 was admitted on March 28, 2025 and was still active at the time of the inspection. A treatment plan update was completed on June 6, 2025 and an update was due no later than August 5, 2025; however, it was not completed until August 8, 2025.Patient #3 was admitted on August 7, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 28, 2025 and an update was due no later than July 27, 2025; however, it was not completed until August 20, 2025.Patient #4 was admitted on December 4, 2020 and was discharged on November 1, 2024. A treatment plan update was completed on August 7, 2024 and the next update was due no later than October 6, 2024; however, it none was completed.Patient #5 was admitted on June 29, 2023 and was still active at the time of the inspection. A treatment plan update was completed on June 3, 2025 and an update was due no later than August 2, 2025; however, it was not completed until August 18, 2025. Patient #7 was admitted on July 13, 2021 and was discharged October 31, 2024. A treatment plan update was completed on August 15, 2024 and an update was due no later than October 14, 2024; however, none was completed. Patient #9 was admitted on May 22, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 27, 2025 and the next update was due no later than July 26, 2025; however, it was not completed until August 12, 2025.Patient #10 was admitted on January 30, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 5, 2025 and an update was due no later than July 4, 2025; however, it was not completed until July 16, 2025. Patient #12 was admitted on October 30, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 21, 2025 and an update was due no later than July 20, 2025; however, it was not completed until August 13, 2025. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the September 12, 2023 and September 16, 2024 licensing inspections.
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Plan of Correction
The Executive Director conducted a review with all counselors emphasizing the importance of obtaining all signatures on treatment plans within three (3) days of their completion. This will be completed by adding stop doses to patients KIPU charts when the treatment plans are reviewed virtually and also by encouraging patients to sign up for the patient portal. Additionally, the supervisor will ensure counselors complete the treatment plan review in the designated "Treatment Plan Review" tab on Kipu. This training was reviewed by the Clinical Supervisor with all clinical staff on October 9, 2025.
To maintain compliance and quality, counselors' treatment plans will be monitored weekly through the overdue treatment plan report. The accuracy and completeness of treatment plans will be evaluated through quarterly peer review audits as well as monthly DQRAT audits, which assess both the completion status and the content quality of the treatment plans.
In addition, on October 2, 2025, the Executive Director submitted for an exemption waiver to have any patients who are compliant with treatment and have been in treatment for over 1 year to be able to move to 120 days treatment plan review schedule, which would reduce the risk for reoccurrence of this citation. This was also at the suggestion of the onsite auditor
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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 document an aftercare plan within guidelines established by the facility's policy and procedures manual in one out of three applicable records reviewed. The facility's policy and procedures manual states that aftercare plans must be completed prior to discharge.Patient #4 was admitted on December 2, 20290 and was successfully discharged on November 1, 2024. No aftercare plan was completed.This finding was reviewed with facility staff during the licensing inspection.
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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 Executive Director conducted a training on October 9, 2025. This training included a comprehensive review of aftercare planning protocols. The Primary Counselor will ensure that all patients have the Transition/Aftercare Plan completed within 90 days of entering treatment (unless indicated before this time) a review of that this has been completed will be added to the quarterly Peer reviews for annual requirements. Should any Transition/Aftercare Plans not be completed when this is reviewed, the POC will indicate this to be completed within 30 days, and the Clinical Supervisor and/or Executive Director will follow up to ensure this is completed to verify compliance and prevent recurrence of deficiencies. |
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 patient records, the facility failed to comply with plans of correction that were approved by the Department. Plans of corrections for treatment plan updates, annual clinical evaluations and annual physical examinations were submitted and approved by the Department for the September 12, 2023 and September 16, 2024 annual licensing inspections. Treatment plan updates, annual clinical evaluations and annual physical examinations were again found to be a deficiency in the September 30-October 1, 2025 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
: The plan for corrections was followed however did not completely resolve deficient areas. Due to repeated citations related to Treatment Plan Updates, Annual Clinical Evaluations, and Annual Physical Examinations, the following corrective measures have been implemented to prevent future deficiencies:
Treatment Plan Updates
Clinicians have conducted a comprehensive review of their caseloads to close outdated treatment plans, update existing ones, and develop new plans as needed. This process included discontinuing participation in monthly group sessions where applicable.
To maintain compliance moving forward:
- The clinical team receives weekly updates from the Clinical Supervisor or Executive Director identifying patients whose treatment plans are due for updates.
- On October 2, 2025, the Executive Director submitted a waiver request to the state, proposing an extension of the treatment plan update requirement to every 120 days for patients who have maintained successful engagement in treatment for over one year.
Annual Clinical Evaluations
A new tracking tool, the Annual Clinical Review Report, has been developed to monitor and ensure timely completion of annual reviews. The Executive Director will run this report in conjunction with an admissions report to identify patients due for review.
- Patients who have not yet had an annual review will be scheduled based on their admission/anniversary date.
- Patients with a prior annual review will be scheduled based on the date of their last completed evaluation, which will be obtained from the Annual clinical review report.
- Clinical staff will receive monthly email notifications indicating which patients on their caseload require an annual clinical review in the upcoming month.
- The Clinical Supervisor will perform regular chart audits to verify compliance and document findings using the ARS Quarterly Audit Tool.
Annual Physical Examinations
The Executive Director will utilize both the Medical Dashboard Bi Report and the patient admissions report to identify upcoming physical examination due dates.
- Patients who have not yet received an annual physical will be scheduled based on their admission/anniversary date.
- Patients with a prior physical will be scheduled according to the date of their last completed examination.
- The Director of Nursing or designated medical provider will:
o Flag patient charts 60 days prior to the due date to initiate scheduling.
o Place a stop-dose flag on charts 30 days before the due date if the physical has not yet been completed.
- The Executive Director and/or Clinical Supervisor will audit charts to ensure compliance and document results using the ARS Quarterly Audit Tool.
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