INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on May 11-12, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MedMark Treatment Centers of Pennsylvania, Inc. DBA: MedMark Treatment Centers - Greensburg 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 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. |
715.20(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 facility failed to document transfer of patient files to the patient's new treatment facility in one out of two applicable records.
Patient #2 was admitted on August 6, 2024 and was discharged on January 5, 2026. At the time of the inspection there was no documentation that facility transferred patient files to the new facility.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Staff will be provided a training on the state requirements for patient transfers. This training will occur on May 27, 2026 by the Clinical Supervisor. Ongoing compliance will be monitored by the Facility Director when conducting random, monthly chart audits. |
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 document an annual clinical evaluation within the regulatory timeframe in one out of four applicable records.
Patient #5 was admitted on July 1, 2024 and was discharged on April 1, 2026. The annual clinical evaluation was due on July 1, 2025; however, it was completed on July 18, 2025.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the May 15-16, 2025 annual licensing inspection.
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Plan of Correction
On Tuesday, 5/19/26, the clinical staff was provided a training by the Clinical Supervisor on Annual Clinical Evaluations to ensure compliance with time frame completion meeting state regulations. Ongoing compliance will be monitored by the Facility Director when completing random, monthly chart audits. |
709.92(a) 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:
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Observations
Based on applicable client records reviewed, the facility failed to provide an initial comprehensive treatment and rehabilitation plan in accordance with the facility policy and procedure manual in one of two records. The facility ' s policy states that the initial comprehensive treatment and rehabilitation plan must be completed within thirty days of admission.
Client #3 was admitted on November 18, 2025 and was still active at the time of the inspection.
The initial comprehensive treatment and rehabilitation plan was to be completed no later than December 18, 2025; however, this was not completed until December 19, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor provided a training to the clinical staff on Tuesday, 5/19/26 to review Treatment Plan completion and the required time frames for completion. The Facility Director will monitor ongoing compliance when conducting random, monthly chart audits. |
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 five of seven applicable records.
Client #1 was admitted on April 16, 2015 and was discharged on January 6, 2026. A treatment and rehabilitation plan update was completed on September 8, 2025. The next treatment and rehabilitation plan update was due no later than November 8, 2025; however, this was not completed until November 10, 2025.
Client #2 was admitted on August 6, 2024 and was discharged on January 5, 2026. A treatment and rehabilitation plan was developed on August 20, 2025. A treatment and rehabilitation plan update was due no later than October 20, 2025; however, this was not completed until October 24, 2025.
Client #3 was admitted on November 18, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on December 19, 2025. A treatment and rehabilitation plan update was due no later than February 19, 2026; however, this was not completed until February 20, 2026.
Client #4 was admitted on January 5, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on November 10, 2025. The next treatment and rehabilitation plan update was due no later than January 10, 2026; however, this was not completed until January 13, 2026.
Client #7 was admitted on January 29, 2025 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on August 28, 2025. The next treatment and rehabilitation plan update was due no later than October 28, 2025; however, this was not completed until October 29, 2025.
The next treatment plan update was due no later than December 29, 2025; however, this was not completed until December 30, 2025.
A treatment and rehabilitation plan update was completed on February 23, 2026. The next treatment and rehabilitation plan update was due no later than April 25, 2026; however, this was not completed until April 30, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor provided a training to the clinical staff on Tuesday, 5/19/26 to review Treatment Plan completion and the required time frames for completion. The Facility Director will monitor ongoing compliance when conducting random, monthly chart audits. |