INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on May 20-21, 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 Washington 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
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in two of two staff records.
Staff #2 was hired as a counselor on September 4, 2024 and was still in this position at the time of the inspection. The HIV/AIDS and TB/STD trainings were to be completed no later than September 4, 2025; however, the trainings were not completed at the time of the inspection.
Staff #3 was hired as a counselor on December 9, 2024 and was still in this position at the time of the inspection. The HIV/AIDS and TB/STD trainings were to be completed no later than December 9, 2025. However, the HIV/AIDS training was not completed until April 10, 2026 and the TB/STD training was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director reviewed the deficiency and re-educated all employees on the requirement that counselors and counselor assistants complete HIV/AIDS and TB/STD training within their first year of employment and that all other staff complete the required training within their first two years of employment.
The Facility Director and Counseling Supervisor will review all current personnel records to ensure compliance and will track required training for all future staff. A training log will be maintained to monitor hire dates, training due dates, and completion dates.
To prevent recurrence, the Facility Director and Counseling Supervisor will conduct monthly reviews of personnel records and the training log. Staff approaching a training due date will be scheduled to complete training before the deadline, and any deficiencies identified will be corrected immediately for all current and future staff to remain compliant.
The facility's training procedures will be revised to include the process for tracking and monitoring HIV/AIDS and TB/STD training requirements for all current and future staff. This corrective action will be implemented on 07/17/2026. |
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 07/30/2026. 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. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one record.
Client #3 was admitted on February 21, 2025 and was discharged on March 20, 2026. There was no documentation in the client record notifying the client, in writing, of termination from the project.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director reviewed the identified patient record and will ensure appropriate documentation of the involuntary termination notice is maintained. The facility director re-educated the departmental leaders (Medical provider, lead nurse, and counseling supervisor) on the requirements of §709.33(a), including the requirement to provide written notification to patients of any involuntary termination decision and the reason for termination. A standardized termination letter and documentation checklist have been implemented to ensure all future involuntary discharges include written notification, documentation of the reason for termination, and evidence of delivery in the patient record. The Facility Director and Clinical Supervisor will review all involuntary terminations prior to record closure and conduct monthly chart audits to ensure ongoing compliance and prevent recurrence of this deficiency. This corrective action will be implemented on 07/17/2026. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on a review of patient records, the facility failed to provide, in writing, documentation that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in one of two applicable records.
Patient #5 was transferred from another narcotic treatment program and admitted on September 30, 2025 and was still active at the time of the inspection. The patient ' s record did not have documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director reviewed the identified transfer record and will send the required documentation to the transferring narcotic treatment program, including notification of the patient's admission and the date of the initial dose. The Facility Director re-educated the counseling supervisor, counselors, and nursing staff on transfer requirements and documentation standards. A transfer checklist has been implemented to ensure all required transfer documentation is received and filed in the patient record prior to closing the transfer process. The transfer checklist will be completed by the counselor and the counselor supervisor will monitor each transfer checklist for completion. The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program. The Facility Director, counseling supervisor, and counselors will review all patient transfers-in and transfers-out monthly during chart audits and monthly staff meetings to verify compliance and prevent recurrence. Additionally, the facility will revise the transfer policy and procedure to ensure documentation requirements and completion timeframes for patient transfers align with applicable state regulations. This corrective action will be implemented on 07/17/2026 |
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.
|
Observations
Based on applicable patient records reviewed, the facility failed to provide documentation of an annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in four of four records. The facility's policy states the annual physical exam will be scheduled one month prior to the patient's anniversary date in treatment. If the appointment is not completed, the patient will be scheduled for another date within one week.
Patient #2 was admitted on August 9, 2022 and was discharged on March 3, 2026. An annual physical exam was due no later than July 31, 2024; however, this was not completed. An annual physical exam was due no later than July 31, 2025; however, this was not completed until December 23, 2025.
Patient #3 was admitted on February 21, 2025 and was discharged on March 20, 2026. An annual physical exam was due no later than January 31, 2026; however, this was not completed until March 2, 2026.
Patient #4 was admitted on May 15, 2025 and was still active at the time of the inspection. An annual physical exam was due no later than April 30, 2026; however, this was not completed at the time of the inspection.
Patient #7 was admitted on April 30, 2025 and was still active at the time of the inspection. An annual physical exam was due no later than March 31, 2026; however, this was not completed until April 14, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 13-14, 2025 annual licensing inspection.
|
Plan of Correction
Annual physical examinations and annual physician reevaluations were completed and/or obtained for the affected patients, and documentation was placed in each patient's clinical record.
The Facility Director reviewed its policy regarding annual physical examinations and annual physician reevaluations with counseling supervisor, counselors, nursing, and medical staff. The annual physical examination tracking process was revised to ensure patients are scheduled at least 30 days prior to their anniversary date in treatment. Patients who miss a scheduled appointment will be rescheduled within one week, in accordance with facility policy.
A tracking log will be maintained by nursing staff and medical providers and reviewed during monthly staff meetings by the Facility Director and Medical Director to monitor upcoming due dates and completion status of annual physical examinations and physician reevaluations.
The Facility Director and nursing staff will conduct monthly audits of active patient records to verify that annual physical examinations and physician reevaluations are completed by the due date and properly documented in the patient record. Audit findings will be reviewed with the Facility and Medical Director and corrective action will be implemented immediately if any deficiencies are identified. Additionally, the facility policy and procedure regarding annual physical examinations will be revised to specify that annual physical examinations be completed within the last day of the anniversary month of NTP admission. This corrective action will be implemented on 07/17/2026.
|
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 evaluation in one of four applicable records.
The facility policy and procedure states the Annual Clinical Assessment is conducted annually.
Patient #3 was admitted on February 21, 2025 and was discharged on March 20, 2026. The annual evaluation was not documented at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the May 13-14, 2025, December 12-13, 2024, July 30-31, 2024, March 27, 2024 and August 9, 2023 licensing inspections.
|
Plan of Correction
The Facility Director re-educated the clinical and medical teams on the facility policy and regulatory requirements for annual patient evaluations. Annual evaluations will be completed on or before the patient's admission anniversary date to the Narcotic Treatment Program (NTP). Counselors are responsible for completing the annual evaluation, and the Medical Director will review, date, and sign each evaluation upon completion.
To ensure ongoing compliance, the Counseling Supervisor will monitor completion of annual evaluations. Counselors and the Counseling Supervisor will track due dates using a tracking spreadsheet, electronic medical record (EMR) reporting, and EMR reminders/holds to ensure evaluations are completed timely. Monthly chart audits will be conducted by the counselors and Counseling Supervisor to verify compliance. Tracking reports and EMR data will be reviewed during monthly team meetings attended by the Facility Director, Counseling Supervisor, and counselors. The counselors and counseling supervisor will be responsible for completion of the annual evaluation for all current and future patients.
Additionally, the facility policy and procedure regarding annual evaluations will be revised to specify that annual evaluations will be completed on or before the patient's admission anniversary date to the Narcotic Treatment Program (NTP). This corrective action will be implemented on 07/17/2026 |
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:
|
Observations
Based on applicable client records reviewed, the facility failed to provide an initial comprehensive treatment and rehabilitation plan in accordance with the facility policy and procedure manual in two of four records. The facility ' s policy states that the initial comprehensive treatment and rehabilitation plan must be completed within thirty days of admission.
Client #6 was admitted on September 3, 2025 and was discharged on April 14, 2026.
The initial comprehensive treatment and rehabilitation plan was to be completed no later than October 3, 2025; however, this was not completed until October 31, 2025.
Client #7 was admitted on April 30, 2025 and was still active at the time of the inspection.
The initial comprehensive treatment and rehabilitation plan was to be completed no later than May 30, 2025; however, this was not completed until July 2, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Counseling staff were re-educated on policy requirements related to treatment plan completion timeframes. Monthly chart audits will be conducted by the Facility Director, Clinical Supervisor, and counselors to ensure continued compliance and prevent recurrence.
All active patient records were reviewed and any missing comprehensive treatment and rehabilitation plans were completed. The counselor is responsible for completing the initial comprehensive treatment and rehabilitation plan within 30 days of admission. The counselor is responsible for tracking due dates and ensuring timely completion. The Facility Director, Clinical Supervisor, counselors are responsible for monitoring compliance through ongoing monthly chart audits and clinical supervision monthly meetings. The facility director, counseling supervisor, and counselors will ensure that all current and future clients have an initial comprehensive treatment and rehabilitation plan completed within 30 days of admission in accordance with facility policy and regulatory requirements. The counselors will keep track of due dates for treatment plans using a spreadsheet, EMR program holds/reminders, and EMR reports; commencing 07/17/2026. |
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.
|
Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in seven of seven applicable records.
Client #1 was admitted on March 31, 2025 and was discharged on December 8, 2025. A treatment and rehabilitation plan update was completed on June 11, 2025. The next treatment and rehabilitation plan update was due no later than August 11, 2025; however, this was not completed until August 22, 2025.
Client #2 was admitted on August 9, 2022 and was discharged on March 3, 2026. A treatment and rehabilitation plan update was completed on April 15, 2025. A treatment and rehabilitation plan update was due no later than June 15, 2025; however, this was not completed until September 19, 2025.
The next treatment plan update was due no later than November 19, 2025; however, this was not completed until December 23, 2025.
The next treatment plan update was due no later than February 23, 2026; however, this was not completed prior to discharge.
Client #3 was admitted on February 21, 2025 and was discharged on March 20, 2026. A treatment and rehabilitation plan update was completed on June 3, 2025. A treatment and rehabilitation plan update was due no later than August 3, 2025; however, this was not completed until August 8, 2025.
The next treatment plan update was due no later than October 8, 2025; however, this was not completed until October 17, 2025.
The next treatment plan update was due no later than December 17, 2025; however, this was not completed until February 19, 2026.
Client #4 was admitted on May 15, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on May 15, 2025. The next treatment and rehabilitation plan update was due no later than July 15, 2025; however, this was not completed until August 18, 2025.
The next treatment plan update was due no later than October 18, 2025; however, this was not completed until October 23, 2025.
The next treatment plan update was due no later than December 23, 2025; however, this was not completed until January 2, 2026.
Additionally, a treatment and rehabilitation plan update was completed on February 4, 2026. The next treatment plan update was due no later than April 6, 2026; however, this was not completed until April 28, 2026.
Client #5 was admitted on September 30, 2025 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan was developed on October 30, 2025. A treatment and rehabilitation plan update was due no later than December 30, 2025; however, this was not completed until May 8, 2026.
Client #6 was admitted on September 3, 2025 and was discharged on April 14, 2026. The comprehensive treatment and rehabilitation plan was developed on October 31, 2025. A treatment and rehabilitation plan update was due no later than December 31, 2025; however, this was not completed until January 12, 2026.
The next treatment plan update was due no later than March 14, 2026; however, this was not completed until March 24, 2026.
Client #7 was admitted on April 30, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on October 24, 2025. The next treatment and rehabilitation plan update was due no later than December 24, 2025; however, this was not completed until January 2, 2026.
The next treatment plan update was due no later than March 4, 2026; however, this was not completed until March 5, 2026.
The next treatment plan update was due no later than May 5, 2026; however, this was not completed until May 11, 2026.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director re-educated the counseling supervisor and counselors on the policy requirements related to treatment plan completion timeframes. Monthly chart audits will be conducted by the Facility Director, Clinical Supervisor, and counselors to ensure continued compliance and prevent recurrence.
All active patient records were reviewed and any missing comprehensive treatment and rehabilitation plans were completed. The counselor is responsible for reviewing and completing a comprehensive treatment and rehabilitation plan at least every sixty (60) days. Each individual treatment and rehabilitation plan will be completed and updated every sixty (60) days, based on the individual's annual date of NTP admission.
The counselor is responsible for tracking due dates and ensuring timely completion. The Facility Director, Clinical Supervisor, and counselors are responsible for monitoring compliance through ongoing monthly chart audits and reviewed during monthly meetings. The facility director, counseling supervisor, and counselors will ensure that all current and future clients have a comprehensive treatment and rehabilitation plan completed and updated at least every 60 days in accordance with facility policy and regulatory requirements. The counselors will keep track of due dates for treatment plans using a spreadsheet, EMR program holds/reminders, and EMR reports; commencing 07/17/2026.
|
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.
|
Observations
Based on client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in seven of seven applicable records. The facility policy and procedure manual indicate a case consultation to occur within three months, six months, nine months, and twelve months of admission, then annually.
Client #1 was admitted on March 31, 2025 and was discharged on December 8, 2025. The three-month case consultation was due to occur no later than July 1, 2026; however, this was not completed prior to discharge. Additionally, the six-month case consultation was due to occur no later than October 1, 2025; however, this was not completed prior to discharge.
Client #2 was admitted on August 9, 2022 and was discharged on March 3, 2026. The annual case consultation was due no later than August 9, 2025; however, this was not completed prior to discharge.
Client #3 was admitted on February 21, 2025 and was discharged on March 20, 2026. The three-month case consultation was due to occur no later than May 21, 2025; however, this was not completed prior to discharge. The six-month case consultation was due to occur no later than August 21, 2025; however, this was not completed prior to discharge. The nine-month case consultation was due to occur no later than November 21, 2025; however, this was not completed prior to discharge. The twelve-month case consultation was due to occur no later than February 21, 2026; however, this was not completed prior to discharge.
Client #4 was admitted on May 15, 2025 and was still active at the time of the inspection. The three-month case consultation was due to occur no later than August 15, 2025; however, this was not completed at the time of the inspection. The six-month case consultation was due to occur no later than November 15, 2025; however, this was not completed at the time of the inspection. The nine-month case consultation was due to occur no later than February 15, 2026; however, this was not completed at the time of the inspection. The twelve-month case consultation was due to occur no later than May 15, 2026; however, this was not completed at the time of the inspection.
Client #5 was admitted on September 30, 2025 and was still active at the time of the inspection. The three-month case consultation was due to occur no later than December 30, 2025; however, this was not completed at the time of the inspection. The six-month case consultation was due to occur no later than March 30, 2026; however, this was not completed at the time of the inspection.
Client #6 was admitted on September 3, 2025 and was discharged on April 14, 2026. The three-month case consultation was due to occur no later than December 3, 2025; however, this was not completed prior to discharge. The six-month case consultation was due to occur no later than March 3, 2026; however, this was not completed prior to discharge.
Client #7 was admitted on April 30, 2025 and was still active at the time of the inspection. The three-month case consultation was due to occur no later than July 30, 2025; however, this was not completed at the time of the inspection. The six-month case consultation was due to occur no later than October 30, 2025; however, this was not completed at the time of the inspection. The nine-month case consultation was due to occur no later than January 30, 2026; however, this was not completed at the time of the inspection. The twelve-month case consultation was due to occur 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 Facility Director reviewed the deficiency and determined that case consultations were not completed in accordance with facility policy and procedure requirements. The Facility Director re-educated the Counseling Supervisor and counselors on the requirement that case consultations be completed at three, six, nine, and twelve months following admission and annually thereafter.
All counselors will be responsible for completing case consultations within the required timeframes and documenting them in the client record. The Counseling Supervisor and counselors will monitor compliance through a tracking spreadsheet and EMR reports. Monthly chart audits will be completed by the facility director, counseling supervisor, and counselors. Compliance with case consultation requirements will be reviewed during monthly clinical team meetings with the Facility Director, Counseling Supervisor, and counselors. Any missed or overdue case consultations for patients will be addressed immediately by counselors. All current and future patients will be compliant. Additionally, the facility policy and procedure regarding case consultations will be revised to clearly define required completion timeframes, including consultations due at three, six, nine, and twelve months following admission and annually thereafter. The Facility Director will oversee implementation of this corrective action to ensure ongoing compliance. This corrective action will be implemented on 07/17/2026
|
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.
|
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 the completion of annual clinical evaluations was submitted and approved by the Department for the May 13-14, 2025, December 12-13, 2024, July 30-31, 2024, March 27, 2024 and August 9, 2023 licensing inspections. The completion of annual clinical evaluations was again found to be a deficiency in the May 20-21, 2026 licensing inspection.
This was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The facility acknowledges that previously approved Plans of Correction were not consistently monitored, resulting in repeat deficiencies. To ensure approved Plans of Correction are followed and sustained, the Facility Director will maintain oversight of all Plans of Correction and assign responsibilities to appropriate department leaders; medical director, lead nurse, and counseling supervisor.
The Facility Director is responsible for ensuring corrective actions are implemented, completed, and maintained to prevent repeat deficiencies. The facility director will monitor compliance through monthly audits, review findings with medical director, lead nurse, and counseling supervisor, document outcomes, and initiate corrective action when noncompliance is identified. Reviewed during monthly staff meetings.
This process will be incorporated into the facility's ongoing quality assurance activities to ensure continued compliance with Department regulations and prevent recurrence of deficiencies. This corrective action will be implemented on 07/17/2026.
|