INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on May 15-16, 2025 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill log for the months of November 2024 through April 2025, the facility failed to maintain a written fire drill record including documentation of whether the fire alarm or smoke detector was operative in four of six logs. December 2024, January 2025, February 2025, and March 2025 fire drill logs did not include the required documentation.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 26-27, 2024 annual licensing inspection.
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Plan of Correction
The Health and Safety Captain and Facility Director reviewed the state regulation regarding fire drills. Moving forward, the smoke detectors in the facility will be checked to ensure that they are operable. The results of these tests will be documented on each month's fire drill log. The Facility Director will ensure compliance by auditing the emergency drills each month when reviewing the "Health and Safety" binder. |
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 eighteen weeks.
Physician service hours were reviewed from December 13, 2024 through April 11, 2025.
During the week of December 30, 2024 through January 3, 2025, the facility's census was 373 patients. The facility was required to provide 37.3 hours of onsite physician services, however they provided only provided 35 hours.
During the week of February 17, 2025 through February 21, 2025, the facility's census was 379 patients. The facility was required to provide 37.9 hours of onsite physician services, however they provided only provided 37 hours.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the August 26-27, 2024 annual licensing inspection.
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Plan of Correction
The Facility Director and Interim Medical Director reviewed the state regulation regarding Physician hours and reviewed the current provider schedules. A plan for coverage was put into place to ensure coverage in the event of a call off. The Facility Director will ensure compliance by reviewing the census and comparing it to each week's Physician hour schedule to make any adjustments for changes in patient census. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on applicable patient records reviewed, the facility failed to provide documentation of an annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in one of five records.
Patient #2 was admitted on October 23, 2018 and was discharged on March 6, 2025. An annual physical exam was completed on October 19, 2023. An annual physical exam was due no later than October 19, 2024; however, this was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director met with the medical staff to go over the state regulations pertaining to physical examinations and when they're due. The team developed a system using the software's "holds" to remind us of due dates to ensure compliance. The Facility Director will monitor ongoing compliance with this 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 of five applicable records.
Patient #4 was admitted on December 27, 2021 and was discharged on March 28, 2025. The annual clinical evaluation has not been completed since December 19, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor held a staff meeting on June 5, 2025 to review the state regulations pertaining to "annual clinical evaluations", which included timeframes for completion, required components and required signatures. The Facility Director will monitor compliance when conducting random, monthly chart audits. |
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 three. The policy and procedure manual indicates follow-up contact must be made within thirty days of discharge.
Client #4 was admitted on December 27, 2021 and was discharged on March 28, 2025. The follow-up contact was due to be completed no later than April 28, 2025; however, this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor reviewed the state regulations and MedMark's policy regarding follow-up with patients post-discharge. The Facility Director will monitor compliance with this when completing chart audits for all discharged patients. |