INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 13, 2025 through November 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, Merakey Parkside Recovery 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 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant inspection conducted at approximately 9:30 a.m. on November 13, 2025, the facility failed to maintain a minimum of two exits on every floor, which are separated by a minimum distance of 15 feet.At the time of the inspection, the facility's second floor secondary exit was identified as being from an office window; however, the fire exit ladder being utilized was not permanently affixed to the building at both the top and the bottom of the ladder.This is a repeat citation from the October 23, 2024 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"1.The facility will remove the non-affixed fire exit ladder from use as a secondary exit. A permanently affixed, code-compliant fire-escape system will be installed on the second floor, secured at both the top and bottom connection points by 1/30/26.
2.The program will educate staff on the code-compliant fire-escape system after installation during the next all-staff meeting by 1/30/26. This training will be documented.
3.Ongoing monitoring: Program leadership will add a safety review of the new code-compliant fire-escape system to the facility checklist. The Program Manager will complete the checklist monthly and provide the results to the Director. Any issues from the facility checklist will be addressed immediately by leadership." |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection conducted at approximately 9:30 a.m. on November 13, 2025, the facility failed to clearly indicate exits by the use of signs.At the time of the inspection, the facility's second floor secondary exit did not have posted exit signs indicating which direction the secondary/emergency exit was. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"1.Program leadership collaborated with the Merakey Facilities Dept. and installed a clearly visible, permanently mounted EXIT sign directing occupants to the second-floor secondary/emergency exit. Signage meets required fire safety visibility standards, including placement, illumination (if applicable), and unobstructed view.
2.The program will educate staff on updated exist signs and fire safety protocols during the next all-staff meeting. This training will be documented.
3.Ongoing monitoring: Program leadership will add a safety review of exit signs to the facility checklist. The Program Manager will complete the checklist monthly and provide the results to the Director. Any issues from the facility checklist will be addressed immediately by leadership." |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant inspection of the facility's mobile unit, conducted on November 14, 2025, the facility failed to ensure the fire extinguisher was inspected and approved annually by the local fire department or fire extinguisher company. At the time of the inspection, the tag on the mobile unit's fire extinguisher had that it was last inspected in March 2018. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"1.The outdated fire extinguisher in the Methadone Mobile Unit (MMU) was removed from service on 11/14/2025. A new, properly inspected and approved fire extinguisher with a current inspection tag was installed in the mobile unit on 11/14/2025.
2.Ongoing monitoring: Beginning in December, the MMU Program Director or designated person will conduct monthly fire extinguisher checks to confirm that each extinguisher has a current inspection tag, is present and unobstructed, and is fully charged and operational. Results will be documented in the Fire Extinguisher Maintenance Log. The MMU Program Director will review the log monthly and ensure immediate corrective action is taken if any deficiencies are identified." |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the narcotic treatment program failed to provide documentation that the narcotic treatment physician conducted the initial face-to-face determination with the patient and prior to the administration of a maintenance agent in two of five applicable patient records reviewed. Patient #5 was admitted on May 14, 2025 and was discharged on June 16, 2025. The physician first prescribed maintenance medication to the patient on May 14, 2025. The initial face-to-face determination was not completed and documented in the facility's electronic medical record until June 26, 2025.Patient #8 was admitted to the mobile unit on November 5, 2025 and was active at the time of the inspection. The physician first prescribed maintenance medication to the patient on November 5, 2025. The initial face-to-face determination was not completed and documented in the facility's electronic medical record until November 10, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"1.The Mobile Unit Program Director will meet with the Medical Director by 12/31/25 to review the regulatory requirement that the face-to-face determination must be completed and documented before any maintenance medication is prescribed. The Medical Director will receive specific instruction on the required time frame and documentation expectations for the dependency determination note. This meeting will be documented.
2.Ongoing monitoring: The Program Director or designated person will conduct monthly audits of all new admissions to verify that the Medical Director or covering physician has completed and documented the face-to-face dependency determination prior to any medication order. Any omissions identified will be addressed immediately with the Medical Director." |
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.
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Observations
Based on a review of patient records, the facility failed to document an informed and voluntary consent in the patient record prior to the administration of an agent one of five applicable patient records reviewed.Patient #4 was admitted on January 28, 2025 and was discharged on May 7, 2025. The patient received their first dose of maintenance medication on January 28, 2025; however, the consent to treat with a narcotic agent was signed by the patient on January 31, 2025. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"1.Executive Director contacted DDAP auditor to discuss this citation The incorrect documentation was provided during inspection. Patient #4's consent document was completed on 1/28/25. Documentation was provided to the auditor to verify this discrepancy. The required documentation will be provided for review next inspection
2.Ongoing monitoring: The Intake Supervisor(s) or designated staff members will conduct monthly audits of new admissions to ensure informed consent is obtained and documented prior to the first dose Any deficiencies will be addressed immediately with the Program Director, and findings will be reviewed with staff and the Medical Director to prevent recurrence." |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient in one of one applicable patient records reviewed. Patient #4 was admitted on January 28, 2025 and was transferred to another narcotic treatment program on May 7, 2025. There was no documentation in the record indicating the receiving narcotic treatment program received the date of admission of the patient, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"1. The Program Director will re-educate the Clinical Supervisor in individual supervision by the end of December on the appropriate procedures with uploading a transfer packet to the client file when the counselor is completing an external transfer.
3. The Program Director will update the Discharge Checklist to include a review of the transfer packet into the electronic health record (EHR). The assigned Counselor will use the Discharge Checklist to complete discharge/transfers.
3. Clinical Supervisor will review the updated Discharge Checklist and review updated procedures with clinical staff in their next upcoming clinical meeting by the end of December.
4. Monitoring: The Clinical Supervisor will review uploaded transfer packets during a review of discharge summaries. If a transfer packet is missing from the record, they will reach out to staff to upload the packet into the EHR. Any issues will be noted in individual supervision." |
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.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in one of one applicable patient record reviewed. Patient #4 was transferred in from another narcotic treatment program on January 28, 2025 and was discharged on May 7, 2025. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the client's date of admission and the date of the initial dose given. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"1. The Program Director will re-educate the Intake/Clinical Supervisor in individual supervision in December on the appropriate procedures when admitting a transferred client. This review is documented.
2. When accepting a transferred client from another program, the Intake/Clinical Supervisor will provide a Letter of Acceptance to the transfer clinic that includes the date of admission of the patient's admission and the date of the initial dose given to the patient. This form will be completed via paper and uploaded in client's EHR during the intake process.
3. The ABH Operations Coordinator will add a review of the Letter of Acceptance to the Intake Monitoring Tool for the Intake Specialist to complete.
4. Monitoring: The Program Director will discuss a sample of completed Intake Monitoring Tools with the Intake Supervisor during monthly individual supervision. This review will be documented as a supervision note." |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure each patient file included the results of an initial intake physical examination in two of five applicable patient records reviewed. Patient #5 was admitted on May 14, 2025 and was discharged on June 16, 2025. The patient received their first dose of maintenance medication on May 14, 2025. The initial intake physical examination was not documented in the facility's electronic medical record system as completed until June 26, 2025.Patient #8 was admitted to the mobile unit on November 5, 2025 and was active at the time of the inspection. The patient received their first dose of maintenance medication on November 5, 2025. The initial intake physical examination was not documented in the facility's electronic medical record system until November 10, 2025.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"1.The Medical Director will complete the intake physical examination on the day of admission or within 7 days after the first dose, in accordance with regulations. Intake nursing staff will notify the Medical Director of any incomplete exams by Day 5 to ensure completion by Day 7.
2.A Physical Examination Tracking Log will be maintained weekly by intake staff. All medical, nursing, and intake staff will receive refresher training by December 20, 2025, covering: Regulatory 7-day timelines, escalation steps for exams not completed by Day 5, requirements for timely and accurate documentation. This training will be documented.
3.For the next 90 days, the Clinical Director or designee will conduct weekly audits of newly admitted patient charts to verify that intake physical examinations are completed within the required 7-day timeframe." |
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 ensure an annual evaluation of the patient's status was completed by the patient's counselor and reviewed, dated, and signed by the medical director in three of three applicable patient records reviewed. Patient #1 was admitted on May 14, 2015 and was active at the of the inspection. The last documented annual evaluation of the patient's status was completed by the counselor on May 15, 2024. There was no documentation of a more recent annual evaluation completed at the time of the inspection.Patient #2 was admitted on August 10, 2020 and was active at the time of the inspection. The last documented annual evaluation of the patient ' s status was completed by the counselor on December 7, 2023. There was no documentation of a more recent annual evaluation completed at the time of the inspection.Patient #3 was admitted on March 8, 2019 and was active at the time of the inspection. There was documentation of an annual evaluation of the patient ' s status completed by the counselor on December 2, 2024; however, the evaluation was not reviewed, dated, and signed by the medical director. This is a repeat citation from the October 23, 2024, annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. The outdated annual evaluations for Patient #2 and Patient #8 will be updated by the assigned counselor at their next kept appointment and sent to the Medical Director for signature/approval (12/31/25)
2. Assigned staff have access to a treatment planning tracker that tracks and monitors upcoming documentation due dates, including annual evaluations. The Clinical Supervisor will review each annual evaluation to ensure it is signed by the Medical Director prior to finalization (1/1/26).
3. The ABH Operations Coordinator will collaborate with the Senior Systems of Care Manager to add the Annual Client Evaluation form to existing program reports to assist in monitoring (1/1/26).
4. Monitoring: The Clinical Supervisor will monitor annual assessment due dates using the treatment planning update tracker with staff through individual supervision and address barriers to completion, as necessary (1/1/26). |
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 a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of four applicable client records reviewed.Client #1 was admitted on August 10, 2020 and was active at the time of the inspection. A treatment plan update was completed on March 25, 2025 and the next update was due to be completed no later than May 25, 2025; however, the update was completed on June 5, 2025. Additionally, a treatment plan update was completed on August 4, 2025 and the next update was due to be completed no later than October 4, 2025; however, the update was completed on October 21, 2025.Client #6 was admitted on January 13, 2025 and was discharged on May 5, 2025. The individual treatment and rehabilitation plan was completed on January 13, 2025, and the first update was due to be completed no later than March 13, 2025; however, the update was not completed prior to discharge. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
"1. The Program Director will review regulatory treatment plan requirements with staff during group supervision in December. This review will be documented as a training sheet.
2. The Program Director will continue to use Power BI, a dashboard tracking and monitoring tool, to track and monitor treatment plan due dates. Upcoming treatment plans due for the month will be discussed during group supervision.
3. The Program Director will review the internal tracking spreadsheet weekly and send email reminders to staff at least 10 business days prior to the expiration on the treatment plan. This will allow additional time for staff to reschedule missed appointments or address ongoing technical issues with the treatment plan to meet regulatory timeframes.
4. To monitor compliance, The Clinical Supervisor will complete chart audits monthly, which will include a review of treatment plan updates. Any missing or late treatment plans will be addressed and documented with staff through individual supervision. Progressive discipline will be enacted, as necessary." |