INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on May 13-14, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MedMark Treatment Centers, Inc. DBA: MedMark Treatment Center - Blairsville 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:
|
Plan of Correction
|
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
Based on a review of administrative information and staff interview, the project failed to document an annual financial audit for the 2023 and 2024 fiscal years.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Management of BayMark Health Services has engaged a public accounting firm, to complete financial audit for December 31, 2023, 2024 and 2025 and the years then ended. Management expects those audits to be completed by the end of Q2 2026. As management does not expect the change in audit firms, reaudits and refinancing process which delayed the audits to recur in future periods, management believes future audits will be submitted by the required deadline. Vice President ? Controller of the Accounting Department will be responsible for timely audit completion. |
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.
|
Observations
Based on a review of patient records, the facility failed to document an annual clinical evaluation that was reviewed, dated, and signed by the medical director within the regulatory timeframe in one four of four applicable records.
Patient #1 was admitted on September 26, 2024 and was still active at the time of the inspection. The annual clinical evaluation was completed by the counselor on August 25, 2025; however, it was not reviewed, dated, and signed by the medical director until January 2, 2026.
Patient #5 was admitted on October 23, 2023 and was discharged on November 19, 2025. The annual clinical evaluation was completed by the counselor on October 10, 2025; however, it was not reviewed, dated, and signed by the medical director until January 2, 2026.
Patient #6 was admitted on July 30, 2017 and was discharged on March 10, 2026. The annual clinical evaluation was completed by the counselor on June 24, 2025; however, it was not reviewed, dated, and signed by the medical director until December 29, 2025.
Patient #7 was admitted on November 29, 2017 and was still active at the time of the inspection. The annual clinical evaluation was completed by the counselor on November 20, 2025; however, it was not reviewed, dated, and signed by the medical director until January 8, 2026.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the May 20-21, 2025 annual licensing inspection.
|
Plan of Correction
All Annual Clinical Evaluations will now be printed out for the Medical Director to sign on paper and then uploaded into SAMMS to ensure the signatures are timely. The Clinical Supervisor will ensure that these get printed and the Facility Director will ensure ongoing compliance when conducting monthly, random chart audits. |
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.
|
Observations
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in one of one record. The policy and procedure manual indicates follow-up contact must be made within thirty days of discharge.
Client #6 was admitted on July 30, 2017 and was discharged on March 10, 2026. The follow-up contact was due to be completed no later than April 30, 2026; however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Staff will go through a review of the documents required for patient discharge during a staff meeting that will be held on May 28th. To ensure compliance, the Counselor Supervisor will review all patient charts upon discharge to ensure that the follow-up contacts are completed. The Facility Director will ensure compliance when conducting random, monthly chart audits. |