INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on May 13-14, 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 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:
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Plan of Correction
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the facility's fire drill log for the months of December 2024 through April 2025, the facility failed to conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts. December 2024, January 2025, February 2025, and March 2025 fire drills were conducted between 11:32am and 11:49am.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Center Director will conduct fire drills at various times throughout the day. Treatment Center Director will ensure that fire drill times vary month to month per state regulations. This citation was corrected on 5/15/25 when the facility conducted a fire drill during peak business hours. Treatment Center Director will continue to place fire drills is binder and be responsible for tracking fire drills and times to ensure that drills take place at various times. Treatment Center Director will monitor on an ongoing basis. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of medical staff coverage, the facility failed to provide narcotic treatment physician services at least one hour per week onsite for every ten patients for fifteen of sixteen weeks.Physician service hours were reviewed from December 23, 2024 through April 11, 2025.During the week of December 23, 2024 through December 27, 2024, the facility's census was 258 patients. The facility was required to provide 25.8 hours of onsite physician services, however they provided only provided 10 hours.During the week of December 30, 2024 through January 3, 2025, the facility's census was 257 patients. The facility was required to provide 25.7 hours of onsite physician services, however they provided only provided 14 hours.During the week of January 6, 2025 through January 10, 2025, the facility's census was 255 patients. The facility was required to provide 25.5 hours of onsite physician services, however they provided only provided 14 hours.During the week of January 13, 2025 through January 17, 2025, the facility's census was 253 patients. The facility was required to provide 25.3 hours of onsite physician services, however they provided only provided 23 hours.During the week of January 27, 2025 through January 31, 2025, the facility's census was 252 patients. The facility was required to provide 25.2 hours of onsite physician services, however they provided only provided 23 hours.During the week of February 3, 2025 through February 7, 2025, the facility's census was 254 patients. The facility was required to provide 25.4 hours of onsite physician services, however they provided only provided 19 hours.During the week of February 10, 2025 through February 14, 2025, the facility's census was 253 patients. The facility was required to provide 25.3 hours of onsite physician services, however they provided only provided 22.5 hours.During the week of February 17, 2025 through February 21, 2025, the facility's census was 249 patients. The facility was required to provide 24.9 hours of onsite physician services, however they provided only provided 23.5 hours.During the week of February 24, 2025 through February 28, 2025, the facility's census was 249 patients. The facility was required to provide 24.9 hours of onsite physician services, however they provided only provided 16.5 hours.During the week of March 3, 2025 through March 7, 2025, the facility's census was 252 patients. The facility was required to provide 25.2 hours of onsite physician services, however they provided only provided 19.5 hours.During the week of March 10, 2025 through March 14, 2025, the facility's census was 250 patients. The facility was required to provide 25 hours of onsite physician services, however they provided only provided 20.5 hours.During the week of March 17, 2025 through March 21, 2025, the facility's census was 251 patients. The facility was required to provide 25.1 hours of onsite physician services, however they provided only provided 12 hours.During the week of March 24, 2025 through March 28, 2025, the facility's census was 252 patients. The facility was required to provide 25.2 hours of onsite physician services, however they provided only provided 15 hours.During the week of March 31, 2025 through April 4, 2025, the facility's census was 253 patients. The facility was required to provide 25.3 hours of onsite physician services, however they provided only provided 15 hours.During the week of April 7, 2025 through April 11, 2025, the facility's census was 255 patients. The facility was required to provide 25.5 hours of onsite physician services, however they provided only provided 14.5 hours.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program medical providers will be scheduled to be onsite 1 hour per week for every 10 patients. An additional medical provider was hired on 5/7/25. Treatment Center Director will schedule providers to ensure hours reflect the patient census. Treatment Center Director will monitor patient census and adjust provider hours accordingly. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the facility's weekly census and physicians' hours, the facility failed to provide documentation of the narcotic treatment physician providing at least one-third of the required narcotic treatment physician time for two of sixteen weeks. The census for week December 23, 2024 through December 27, 2024 was 258. The required narcotic treatment physician time is 25.8. One-third of the required narcotic treatment physician time in 8.6. There were only 8 hours documented.The census for week March 17, 2025 through March 21, 2025 was 251. The required narcotic treatment physician time is 25.1. One-third of the required narcotic treatment physician time in 8.36. There were zero hours documented.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program physician will provide one third of the required time according to the patient census. Treatment Center Director will schedule physician according to census. Treatment Center Director will monitor the patient census weekly and adjust program's physician time as necessary. |
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 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 three of three records.Patient #3 was admitted on April 26, 2018 and was discharged on May 9, 2025. An annual physical exam was completed on January 31, 2024. An annual physical exam was due no later than January 31, 2025; however, this was not completed at the time of the inspection. Patient # 5 was admitted on April 11, 2023 and was still active at the time of the inspection. An annual physican exam was completed on May 9, 2024. An annual physical exam was due no later than May 9, 2025; however, this was not completed at the time of the inspection Patient #6 was admitted on April 22, 2019 and was still active at the time of the inspection. An annual physican exam was completed on April 10, 2024. An annual physical exam was due no later than April 10, 2025; however, this was not completed at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical staff will review all patient charts and place holds for upcoming annual physicals. Medical staff will schedule with patients to complete the annual physical before the due date. Counselors will discuss program requirements with their patients on a regular basis to ensure completion of program requirements in a timely manner. Treatment Center Director will monitor regularly that holds are being honored and annual physicals are completed prior to the due date. |
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 #3 was admitted on April 26, 2018 and was discharged on May 9, 2025. The annual clinical evaluation has not been completed since March 13, 2023.Patient # 5 was admitted on April 11, 2023 and was still active at the time of the inspection. The annual clinical evaluation was due on April 11, 2025; however, it was not completed at the time of the inspection.Patient #6 was admitted on April 22, 2019 and was still active at the time of the inspection. annual clinical evaluation was due on April 22, 2025; however, it was not completed at the time of the inspection.These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the December 12-13, 2024, July 30-31, 2024, March 27, 2024 and August 9, 2023 licensing inspections.
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Plan of Correction
The Counselor Supervisor has implemented weekly meetings with the counseling team to discuss upcoming annual due dates. The Counselors are scheduling annual paperwork with patients before the due date. Counselor Supervisor is monitoring the completion of annual documentation on a weekly basis. On May 19, 2025, the Counselor Supervisor and the counseling team started meeting weekly to discuss upcoming annual paperwork. |
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 applicable client records reviewed, the facility failed to complete an aftercare plan in accordance with the facility policy and procedure manual in one of one records. The facility policy and procedure manual indicated an aftercare plan will be completed with the client for all planned discharges. Client #3 was admitted on April 26, 2018 and successfully completed the program on May 9, 2025. An aftercare plan was not completed at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon planned discharges, Counselors will develop a transition plan with the patient prior to discharge. Counselors have been provided with a checklist to use at discharge, which includes transition plans. Discharge checklist will be submitted to the Counselor Supervisor when discharges and planned discharges occur. Counselor Supervisor will audit to ensure that necessary documentation has been completed. Counselor Supervisor and Treatment Center Director will monitor discharges on a weekly basis to ensure completion when planned discharges occur. |
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 the completion of annual clinical evaluations was submitted and approved by the Department for the 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 13-14, 2025 licensing inspection.This was reviewed with the facility staff during the licensing process.
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Plan of Correction
MedMark Treatment Centers Washington will follow the approved plans of correction to be compliant with state regulations. The Treatment Center Director, Regional Director of Operations and Counselor Supervisor will ensure that the approved plans are reviewed with the staff. Treatment Center Director and Counselor Supervisor will monitor compliance of the plans on a weekly basis. |