INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 5, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Merakey Parkside Recovery was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on staff interviews, the facility failed to follow their dispensing area policy.
The facility ' s " ABH SUD Methadone Procedure " notes " administering and dispensing shall be conducted in manner that protects the individual ' s confidentiality and is provided in a manner that is free from disruption from other individuals. "
Facility staff reported that, in the case of an infectious medical condition, a patient maybe be dosed outside of the door nearest to the elevator. Facility staff reported a patient had been dosed this way in December 2025. Dosing at this location makes the patient visible to anyone in the proximity of the side of the building.
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Plan of Correction
1. The Program Director reviewed client dosing privacy requirements at the all clinical meeting on 3/30/26 and sent a follow-up memo to all staff reiterating "Code 4" protocols for when clients present with an infectious medical condition,
2. The Program Director will update the "ABH SUD Methadone Procedure" to include language about when and how to utilize "Code 4" for individuals. When a client falls under Code 4, the informed staff member will communicate to the Program Director, Nursing Director, and Supervisor of the concern and exposure of onset of symptoms. Staff will use an isolated area in the facility for the client which will ensure the privacy of the client. The program will also maintain a Code 4 List of clients who present with an infectious medical condition.
3. Monitoring - The Program Director and Nursing Director will approve of all individuals added or removed from the Code 4 List and review the list, as needed, when new clients are added or removed. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of patient records, the facility failed to document treatment plan updates within regulatory time frames.
Patient #1 was admitted on August 15, 2022, and was still active at the time of the inspection. A treatment plan update was completed on November 18, 2025, and the next update was due no later than January 18, 2026; however, it was not completed until February 3, 2026.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
1. The Program Director will review regulatory treatment plan requirements with staff during their next scheduled all clinical meeting by 4/30/26 that if individuals are absent from treatment that a treatment plan is still created and upon return to treatment a new treatment plan is created. This review will be documented in the group supervision notes.
2. The Clinical Supervisors will continue to use an internal tracking spreadsheet to track and monitor treatment plan due dates. Upcoming treatment plans due for the month will be discussed during group supervision.
3. The Clinical Supervisors will review the internal tracking spreadsheet weekly and send email reminders to staff at least two business weeks 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. Monitoring: Any missing or late treatment plans will be addressed and documented with staff through individual supervision with the Clinical Supervisor. Progressive discipline will be enacted, as necessary. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan.
Patient #1 was admitted on August 15, 2022, and was still active at the time of the inspection. A treatment plan update was completed on November 18, 2025, noted the patient was to receive one individual therapy session on a biweekly basis. There were no individual sessions documented for the period of December 30, 2025 through January 19, 2026.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
1. The Program Director will review the requirement that counseling services need to be provided in accordance to the individual treatment plan with all clinical staff during their next scheduled group supervision in April. Patient #1 has been attending therapy sessions in accordance to their treatment plan.
2. Moving forward, staff will update the client's treatment plan if/when the client experiences barriers to attending scheduled therapy sessions in accordance with the treatment plan.
3. Monitoring: The Clinical Supervisor will review the need to update treatment plans with clinical staff through individual supervision, as needed. The team also completes quarterly chart audits that reviews frequency and duration of interventions. |