INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted September 8, 2026 through September 10, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Associates, LLC dba Mount Pocono Medical 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
|
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on a review of administrative documents, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
The last documented sign-off from the project director was dated January 15, 2025, and the next one was due no later than January 15, 2026; however, the documentation provided was dated August 11, 2026, and signed by the compliance specialist. When the document was reviewed with the project director, their signature was also added on to the document.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Mount Pocono Facility Director will review the nature and background for the need of annual update and the need of sign-off of the written manual delineating project policies and procedures in upcoming 10/21/26 Staff Meeting and Clinical Supervisor reviewed in 10/7/26 clinical meeting.
The Project Director will review and ensure policies are updated and issue a signed attestation to that effect annually at the beginning of each year.
|
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
|
Observations
Based on a review of patient records, the program failed to obtain a patient consent to contact the referring narcotic treatment program for the patient ' s treatment history in one of three applicable records reviewed.
Patient #3 was transferred in on March 25, 2026 and was discharged on July 24, 2026. There was no documentation that the facility sent the transferring narcotic treatment program verification of the patient' s treatment history.
This finding was reviewed with program staff during the licensing process.
|
Plan of Correction
All intakes will have intake chart audits completed once a week to review documents in EMR and to determine whether anything was missing. This will be completed utilizing safety culture Mitti. QI will conduct 6 chart audits quarterly to ensure compliance for all POC that require chart audits to be completed. Front desk will notify nursing whether intake is a transfer or not. Daily nursing will not dose patient until transfer paperwork from transferring facility is uploaded. Nurses will review and sign off on the Intake Nurses note to ensure that other documents are complete and signed prior to dosing the patient. A new intake check list will revised. Staff were provided a re-education training during team meeting on October 7th.
Management including clinical supervisor and director will conduct weekly intake audits to verify completion of all induction documents including transfer paperwork to be uploaded. Will monitor nursing to ensure documents were uploaded prior to dosing. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to administering an agent in one out of eight applicable records reviewed.
Patient #4 was admitted on January 7, 2026, and was active at the time of the licensing inspection. Patient #4 was administered an agent on January 7, 2026, however; the informed, voluntary, written consent was not signed until January 8, 2026.
This finding was reviewed with program staff during the licensing process.
|
Plan of Correction
All intakes will have intake chart audits completed once a week to review documents in EMR and to determine whether anything was missing. This will be documented in safety culture Mitti. QI will conduct 6 chart audits quarterly to ensure compliance for all POC that require chart audits to be completed. Nurses will review and sign off on the Intake Nurses note to ensure that other documents including Consent for MOUD are complete and signed prior to dosing the patient. A new intake check list will revised. Staff were provided a re-education training during team meeting on October 7th.
Management including clinical supervisor and director will monitor intakes daily to verify completion of all induction documents and signatures are completed prior to dosing. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
|
Observations
Based on review of patient records, the program failed to maintain onsite a photograph of each patient that included the patient's name and birth date, as well as update the photograph every 3 years in one of eight records reviewed.
Patient #5 was admitted on April 7, 2016, and was active at the time of the inspection. The photograph in the record was dated February 11, 2016, and was due to be updated by February 11, 2019. No other forms of identification with an updated photograph were in the record at the time of the inspection.
This finding was reviewed with program staff during the licensing process.
|
Plan of Correction
When monthly chart audits are conducted, ID/drivers licenses will be reviewed to determine whether valid or not. QI will conduct 6 chart audits quarterly to ensure compliance for all POC that require chart audits to be completed. Updated ID/Drivers licenses will be updated as needed and part of annual clinical reviews by counseling team. A new annual check list was be handed out to staff at group supervision on Oct/7th/26 to follow when reviewing charts annually.
Clinical supervisor will monitor during audits monthly and review annual documentation after staff completed annual review for patients each month. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
Based on a review of patient records, the facility failed to document the results of an in-person initial intake physical examination within 14 days of a telehealth induction in one of two applicable patient records reviewed.
Patient #4 was admitted on January 7, 2026, and was active at the time of the inspection. A telehealth induction was completed with the patient on January 7, 2026. An in-person physical examination was due no later than January 21, 2026; however, it was not completed until February 4, 2026.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
Was reviewed on October 7th with nursing and medical provider that paperwork for intakes including in house physical examination needs to be signed by both patient and provider on the same day to avoid it being overdue beyond the 14 days. Staff were provided a re-education training during team meeting on October 7th.
Management including clinical supervisor and director will monitor intakes that require in house physical examination to ensure it is signed same day to avoid documentation from being late passed the 14 days of initial intake. |
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 document the notification of the previous narcotic treatment program of the admission and initial dose of the patient in one out of three applicable records reviewed.
Patient #3 was transferred in on March 25, 2026, and was discharged on July 24, 2026. There was no documentation that the facility sent the transferring narcotic treatment program verification of the patient' s admission date or the initial dose given to the patient.
This finding was reviewed with program staff during the licensing process.
|
Plan of Correction
Nursing will upload the fax confirmation and form associated with the transfer to verify that is was completed. All intakes will have intake chart audits to review documents in EMR and to determine whether anything was missing. Front desk will notify nursing whether intake is a transfer or not. A new intake check list for nursing will revised where the acknowledgement of the admission will be faxed to previous treatment facility on the same day of admission. Staff were provided a re-education training during team meeting on October 7th.
Management including clinical supervisor and director will monitor any transfer intakes daily to verify completion of acknowledgement letter to verify admission before end of the business day. |