INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on March 3-4, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Polaris Renewal Services Inc. MedMark Treatment Centers Perryopolis 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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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.
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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.
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Plan of Correction
Management of BayMark Health Services has engaged Baker Tilly, 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. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in two of three records.Client #2 was admitted on July 17, 2025 and was still active at the time of the inspection. The treatment plan was dated August 14, 2025.Client #3 was admitted on May 13, 2025 and was still active at the time of the inspection. The treatment plan was dated June 19, 2025.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 03/20/2026, the Facility Director re educated the clinical team on the policy and procedure related to the development of individualized treatment and rehabilitation plans, with specific emphasis on the requirement that each plan include the proposed type of support services. The clinical team will ensure support services are documented in each treatment plan using audit tools, and the counseling supervisor will review plans for completeness; commencing 04/10/2026 |
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.
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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 six of seven applicable records.Client #1 was admitted on March 15, 2016 and was still active at the time of the inspection. A treatment plan update was completed on September 24, 2025 and the next update was due no later than November 24, 2025; however, the update was completed on November 28, 2025. Client #3 was admitted on May 13, 2025 and was still active at the time of the inspection. The comprehensive treatment plan was developed on June 19, 2025. A treatment plan update was due no later than August 19, 2025; however, the update was completed on August 22, 2025. Additionally, a treatment plan update was completed on October 17, 2025 and the next update was due no later than December 17, 2025; however, the update was completed on December 22, 2025.Client #4 was admitted on December 11, 2012 and was still active at the time of the inspection. A treatment plan update was completed on June 10, 2025 and the next update was due no later than August 10, 2025; however, the update was completed on August 11, 2025. Additionally, a treatment plan update was completed on October 9, 2025 and the next update was due no later than December 9, 2025; however, the update was completed on December 10, 2025. The next update was due no later than February 10, 2026; however, the update was not completed until February 11, 2026.Client #5 was admitted on May 2, 2016 and was discharged on June 13, 2025. A treatment plan update was completed on March 18, 2025 and the next update was due no later than May 18, 2025; however, the update was completed on May 21, 2025. Client #6 was admitted on May 9, 2025 and was discharged on January 13, 2026. A treatment plan update was completed on August 13, 2025 and the next update was due no later than October 13, 2025; however, the update was completed on November 7, 2025. Client #7 was admitted on November 26, 2024 and was discharged on January 12, 2026. A treatment plan update was completed on March 7, 2025 and the next update was due no later than May 7, 2025; however, the update was completed on May 14, 2025. Additionally, a treatment plan update was completed on July 14, 2025 and the next update was due no later than September 14, 2025; however, the update was completed on September 17, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 03/20/2026, the Facility Director re- educated the clinical team on the policy and procedure requiring that treatment and rehabilitation plans be reviewed and updated 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 admission.The clinical team will keep track of due dates for treatment plans using a spreadsheet, SAMMs program holds/reminders, and SAMMs reports; commencing 04/10/2026. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on applicable client records reviewed, the facility failed to complete discharge summaries in accordance with the facility policy and procedure manual in one of three records. The policy and procedure manual indicates discharge summaries must be completed within seven days of discharge.Client #5 was admitted on May 2, 2016 and was discharged on June 13, 2025. The discharge summary was to be completed no later than June 20, 2025; however, this was not completed until July 15, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 03/20/2026, the Facility Director re- educated the clinical team on the policy and procedure requiring that discharge summaries be completed within seven (7) days of discharge. All discharge summaries will be completed within seven days of the individual's discharge. The clinical team will track due dates for discharge documentation using a spreadsheet, discharge summary checklist, and SAMMs program holds/reminders; commencing 04/10/2026. |
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.
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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 two records. The policy and procedure manual indicates follow-up contact must be made at seven and thirty days after discharge.Client #5 was admitted on May 2, 2016 and was discharged on June 13, 2025. The seven-day follow-up contact was due no later than June 20, 2025; however, this was not completed until July 9, 2025. Additionally, the thirty-day follow-up contact was due no later than July 13, 2025; however, this was not completed until July 16, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 03/20/2026, the Facility Director re- educated the clinical team on the policy and procedure regarding post discharge follow up contact requirements. Follow up contact will be completed at seven (7) days and thirty (30) days following discharge for each individual. The clinical team will keep track of due dates for follow-up contact using a spreadsheet, discharge summary checklist, and SAMMs program holds/reminders; commencing 04/10/2026. |