INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on February 24-25, 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 Lemont Furnace 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of applicable staff records, the facility failed to provide a mechanism to provide feedback on a completed training in accordance with the facility policy and procedure manual in two of two records.
The facility policy and procedure manual indicated that staff are to complete training feedback once the training is completed.
Staff #3 was hired on as a counselor on April 7, 2023 and was still in this position at the time of the inspection. The facility was unable to provide feedback collected from trainings Staff #3 had participated in during 2025 training year.
Staff #6 was hired on as a counselor on January 22, 2024 and was still in this position at the time of the inspection. The facility was unable to provide feedback collected from trainings Staff #6 had participated in during 2025 training year.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 10-11, 2025 annual licensing inspection.
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Plan of Correction
Facility Director will implement a tracking system to ensure compliance with feedback form completion This system will be reviewed with staff to allow for education and understanding of required state regulations. The Facility Director and Counseling Supervisor will collect and maintain all completed feedback forms and match them with training sessions. Feedback forms will be developed for all training completed by staff. |
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.
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Observations
Based on a review of applicable staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in three of three staff records.
Staff #1 was hired on as the project director and facility director on January 13, 2025 and was still in this position at the time of the inspection. HIV/AIDS training was to be completed by January 12, 2026. There was no documentation that this training was completed.
Staff #3 was hired on as a counselor on April 7, 2023 and was still in this position at the time of the inspection. HIV/AIDS training was to be completed by April 7, 2024. There was no documentation that this training was completed.
Staff #6 was hired on as a counselor on January 22, 2024 and was still in this position at the time of the inspection. HIV/AIDS training was to be completed by January 22, 2025. There was no documentation that this training was completed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 10-11, 2025 annual licensing inspection.
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Plan of Correction
The Facility Director will ensure that all new clinical employees are scheduled for DDAP self-directed HIV/AIDS and In-House TB/STD training within their first quarter of employment. The Facility Director will keep updated personnel records with training records for each staff member to ensure all staff comply with the training requirements. The Facility Director will ensure ongoing compliance with this when creating a training plan for each employee and by auditing employee records for compliance. |
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. |
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 two of seventeen weeks.
Physician service hours were reviewed from September 7, 2025 through January 2, 2026.
During the week of December 22, 2025 through December 26, 2025, the facility ' s census was 271 patients. The facility was required to provide 27.1 hours of onsite physician services, however they provided only provided 22.58 hours.
During the week of December 29, 2025 through January 2, 2026, the facility ' s census was 272 patients. The facility was required to provide 27.2 hours of onsite physician services, however they provided only provided 24.35 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. 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.
The census for week December 29, 2025 through January 2, 2026 was 272. The required narcotic treatment physician time is 27.2. One-third of the required narcotic treatment physician time in 8.96. There were only 8.6 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(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 applicable patient records reviewed, the facility failed to have an annual evaluation of each patient ' s status that was completed by the patient ' s counselor and was reviewed, dated, and signed by the medical director in three of four records. The annual evaluation period shall start on the date of the patient ' s admission to a narcotic treatment program.
Patient #2 was admitted on September 13, 2022 and was discharged on February 11, 2026. The annual evaluation was due by September 13, 2025; however, this was not completed prior to discharge.
Patient #3 was admitted on August 8, 2024 and was discharged on November 28, 2025. The annual evaluation was due by August 8, 2025; however, this was not completed prior to discharge.
Patient #4 was admitted on June 24, 2024 and was still active at the time of the inspection. The annual evaluation completed on June 16, 2025; however, this was not signed by the medical director at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 10-11, 2025 and February 26-27, 2024 annual licensing inspections.
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Plan of Correction
The Counselor Supervisor has implemented daily contacts with the counseling team to discuss upcoming annual due dates. The Counselors are scheduling annual paperwork with patients before the due date. Counseling Supervisor is monitoring the completion of annual documentation daily. The Counseling Supervisor and the counseling team have started daily discussions on upcoming annual paperwork. |
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 one of one records.
Client #5 was admitted on December 1, 2025 and was still active at the time of the inspection. The treatment plan was dated December 30, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Counseling Supervisor will provide mandatory training to all counselors on identifying and documenting supportive services aligned with ASAM dimensions 1-6. Counseling Supervisor will audit 5 charts per week for the first 30 days after training and provide feedback during weekly supervisions. Afterwards, 5 charts per month will be audited |
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 four applicable records.
Client #2 was admitted on September 13, 2022 and was discharged on February 11, 2026. A treatment plan update was completed on May 20, 2024 and the next update was not completed until September 5, 2025.
Client #3 was admitted on August 8, 2024 and was discharged on November 28, 2025. A treatment plan update was completed on July 24, 2025 and the next update was due no later than September 24, 2025; however, the update was completed on September 29, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 10-11, 2025, February 26-27, 2024 and March 15-16, 2023 annual licensing inspections.
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Plan of Correction
The Facility Director is responsible for ensuring that the treatment plans are updated as required. The Facility Director and Counseling Supervisor will meet with the counselors and remind them of the regulation and utilization of the tracking sheet to assist them with compliance. Random audits will be performed weekly on each tracking sheet. It shall be the responsibility of the Counseling Supervisor to ensure program staff are trained by the Clinical Training Manager on the proper completion of the comprehensive treatment plan including patients participating in the treatment planning session and signing their treatment plan. |
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 #1 was admitted on January 24, 2023 and was discharged on April 3, 2025. There was no documentation of the thirty-day follow-up being completed.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the March 10-11, 2025, February 26-27, 2024 and March 15-16, 2023 annual licensing inspections.
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Plan of Correction
The Facility Director will provide training regarding updated follow-up policy and procedure. The follow-up call must be completed within thirty days after discharge. The Counseling Supervisor will utilize random monthly chart audits to ensure adherence to this requirement. The Counseling Supervisor will utilize weekly individual supervision and coaching to document any deficiency for individual counselors. |
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 March 10-11, 2025, February 26-27, 2024 and March 15-16, 2023 annual licensing inspections. Treatment plan updates were again found to be a deficiency in the February 24-25, 2026 annual licensing inspection.
A plan of correction for follow-up contact was submitted and approved by the Department for the March 10-11, 2025, February 26-27, 2024 and March 15-16, 2023 annual licensing inspections. Follow-up contact was again found to be a deficiency in the February 24-25, 2025 annual licensing inspection.
A plan of correction for annual evaluations for each patient's status was submitted and approved by the Department for the March 10-11, 2025 and February 26-27, 2024 annual licensing inspections. Annual evaluations were again found to be a deficiency in the February 24-25, 2025 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 10-11, 2025 annual licensing inspection.
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Plan of Correction
Facility Director and Counseling Supervisor, in conjunction with the Regional Director of Operations, will develop Plans of Correction to submit to the Department. Once accepted, Facility Director and Regional Director of Operations will create, review, and implement regular audits of the facility's compliance to all accepted plans of correction submitted and approved by the Department. |