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 6, 2025 through November 7, 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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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 includes the admission date, medical and psychosocial summaries, dosage levels, urinalysis reports or summary, exception requests, current status of the patient, and written consent of the patient, in one of two applicable patient records reviewed.
Patient #6 was admitted on August 15, 2024 and was transferred out on March 6, 2025. There was no documentation in the record indicating the receiving narcotic treatment program was notified of the urinalysis reports or summary.
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. |
715.23(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 was then reviewed, dated, and signed by the medical director, in two of three applicable patient records reviewed.
Patient #2 was admitted on January 13, 2020 and was active at the time of the inspection. The last annual evaluation of the patient's status, documented in the record, was completed by the counselor in 2023. There was no other annual evaluation documented in the record at the time of the inspection.
Patient #8 was admitted on March 7, 2019 and was active at the time of the inspection. The last annual evaluation of the patient ' s status was completed by the counselor on March 6, 2023. There was no other annual evaluation documented in the record at the time of the inspection.
This is a repeat citation from the October 25, 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.
2. Assigned staff have access to a treatment planning tracker that tracks and monitors upcoming documentation due dates, including annual evaluations.
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.
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. |