INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on May 21, 2025 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 of Pennsylvania, Inc. DBA: MedMark Treatment Centers - 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:
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Plan of Correction
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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 a review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in three of three applicable records.
Patient #5 was admitted on October 24, 2022 and discharged January 9, 2025. The annual clinical evaluation was due on October 24, 2024; however, it was not completed at the time of the inspection.
Patient #6 was admitted on September 9, 2019 and was discharged on March 6, 2025. The annual clinical evaluation had not been completed since September 21, 2023.
Patient #7 was admitted on March 24, 2022 and was still active at the time of the inspection. annual clinical evaluation was completed on January 27, 2025; however, it was not reviewed, dated, and signed by the medical director at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor held a staff meeting on 6/2/25 to review the state regulation for annual clinical evaluation completion. The Facility Director will monitor ongoing compliance when randomly auditing patient files each month. |
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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two of six applicable records.
Client #3 was admitted on June 24, 2024 and was discharged April 8, 2025. A treatment and rehabilitation plan was developed on November 6, 2024. A treatment and rehabilitation plan update was due no later than January 6, 2025, but was not completed until January 21, 2025.
Client #6 was admitted on September 9, 2019 and was discharged on March 6, 2025. A treatment and rehabilitation plan was developed on November 8, 2024. A treatment and rehabilitation plan update was due no later than January 8, 2025, but was not completed until January 14, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 27-28, 2024, July 25, 2023 and July 6-7, 2022 annual licensing inspections.
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Plan of Correction
The Clinical Supervisor reviewed the state regulation regarding treatment plan completion during the staff meeting that was held on 6/2/25. The Facility Director will monitor ongoing compliance when conducting random, monthly chart audits and will address concerns with the individual counselors as needed. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure in three of five applicable records.
The facility policy and procedure indicates a case consultation to occur every three months for the first year, then annually thereafter.
Client #3 was admitted on June 24, 2024 and was discharged April 8, 2025. A case consultation was due to occur no later than September 24, 2024, however this was not completed until March 19, 2025.
Client #5 was admitted on October 24, 2022 and discharged January 9, 2025. An annual case consultation was due to occur no later than September 21, 2024, however this was not completed at the time of the inspection.
Client #6 was admitted on September 9, 2019 and was discharged on March 6, 2025. An annual case consultation was due to occur no later than September 21, 2024, however this was not completed prior to discharge.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed the state regulation for case consultation completion during the staff meeting that was held on 6/2/25. The Facility Director will monitor case consultation completion when completing random, monthly chart audits and will address any individual concerns with the primary counselor. |
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.
A plan of correction for treatment plan updates was submitted and approved by the Department for the August 27-28, 2024, July 25, 2023 and July 6-7, 2022 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the May 21, 2025 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 27-28, 2024 annual licensing inspection.
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Plan of Correction
The plan of corrections regarding treatment plans from the 3 previous state audits were reviewed with the management team during our meeting held on 5/30/25. To ensure compliance moving forward, the Facility Director will increase the amount of charts that are randomly audited each month. The Facility Director will monitor 10 files from each counselors' caseload to address a larger sample each month. Any individual counselor who is struggling with compliance will be placed on a "performance improvement plan". |