INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20, 2025 through August 21, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Associates, LLC dba Mount Pocono Medical 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 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records and staff training records, the project failed to instruct all staff in the use of the fire extinguisher upon employment in one of five records reviewed. Employee #5 was hired as a counselor on June 25, 2025, and was current in that position at the time of the inspection. The employee was to be instructed in the use of the fire extinguisher upon employment; however, the employee did not receive this training as of the date of the licensing inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Moving forward all employees upon hire will complete fire safety / fire extinguisher training within the first three days of their hired date. Pinnacle U trainings will be printed out on day one and followed as a guide daily to ensure trainings are not missed for new hires.
Management including Clinical supervisor and Director will track daily on pinnacle U trainings to ensure trainings are being completed by the new hires within three days. This new approach will begin on 9/29/2025 to ensure compliance is maintained. Employee #5 will be trained on 9/29/2025 regarding fire extinguisher training. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on the review of the fire drill log from September 2024 through July 2025, the facility failed to conduct fire drills during normal staffing conditions. The fire drills conducted in the months of January 2025, February 2025, March 2025, April 2025, June 2025 and July 2025 were conducted when the facility was closed.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Fire drills will occur at random times during hours of operations between 5:30am to 12pm each month instead after dispensing. Review of past fire drills will be on 9/29/2025 to ensure there is no pattern when conducting them in the future. Director will review with QI quarterly on process and procedures as well as any updates regarding conduction of fire drills.
Director will monitor completion of Fire Drills at random times during hours of operations between 5:30am to 12pm each month. This will be completed minimum of once a month. Quarterly will review with QI for any updates. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records and staff training records, the project failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one of five records reviewed. Employee #5 was hired as a counselor on June 25, 2025, and was current in that position at the time of the inspection. The employee was to be trained to perform assigned tasks during emergencies prior to working a shift; however, the employee did not receive this as of the date of the inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Moving forward all employees upon hire will complete Fire safety / fire drill training within the first three days of their hired date. Pinnacle U trainings will be printed out on day one and followed as a guide daily to ensure trainings are not missed for new hires. Management including Clinical supervisor and Director will track daily on pinnacle U trainings to ensure they are being completed by the new hires within three days. This new approach will begin on 9/29/2025. A print out will be given to new hires to track as well daily. This will be monitored on day one of each new hire start date. Employee #5 will be trained on 9/29/2025. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill log from September 2024 through July 2025, the facility failed to conduct fire drills on different days of the week, different times of the day and night on different staffing shifts. The fire drills conducted in the months of January 2025, April 2025, May 2025 and June 2025 were conducted on the last business day of the month.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Fire drills will occur during random days of the month rather than last day of the month. Review of past fire drills will be on 9/29/2025 to ensure there is no pattern when conducting them in the future. Director will review with QI quarterly on process and procedures as well as any updates regarding conduction of fire drills. Director will monitor completion of fire drills to be completed at random days. Beginning of each month with randomly select a day for a fire drill to be conducted. This will be completed minimum of once a month. Quarterly will review with QI for any updates. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of nine records reviewed.Client #5 was admitted on January 24, 2025 and was discharged on March 29, 2025. The facility failed to document a release of information for the funding source; however, it was verified that billing had occurred. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
All intakes will have intake chart audits to review documents in EMR along with all signatures accounted for. A new intake check list will be handed out to staff at next group supervision on 9/29/25 to follow when conducting an intake.
Management including clinical supervisor and director will conduct weekly intake audits to verify completion of all induction documents. Will monitor all staff that were part of induction to complete any overdue items by end of the day once audit is complete. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one applicable client record reviewed.Client #7 was admitted on July 28, 2014 and was involuntarily discharged on October 23, 2024. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Patient will receive a notice in writing including reason for termination and will upload in their EMR. Staff will be trained on the process when there is an involuntary decision to terminate a patient's treatment on 9/29/2025 in group supervision.
Management including clinical supervisor and director will monitor in the completion of this process if there are decisions for involuntary termination of a patient on same day of incident. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify a patient ' s identity, which included the name, address, date of birth, emergency contact and other identifying information prior to the administration of an agent in one of nine patient records reviewed.Patient #5 was admitted on January 24, 2025 and was discharged March 29, 2025. There was no documentation that the patient ' s identity was verified prior to the administration of an agent. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Will review induction process regarding intakes of all kinds including obtaining ID and having documented emergency contact information in group supervision on 9/29/2025. Will provide new induction sheets for all staff to follow when conducting an new admission.
Will update induction guide sheets to hand out on 9/29/25 to provide to all staff to follow when there is a new admission. Will review updated induction guide sheets during group supervision on 9/29/2025. Management will review once a week through use of intake chart audits to review 100% of inductions completed to ensure documents are completed in a timely manner. |
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 obtain an informed, voluntary, written consent before an agent may be administered in one of nine patient records reviewed.Patient #5 was admitted on January 24, 2025 and was discharged March 29, 2025. There was no informed, voluntary, written consent documented in the record before an agent was administered.This is a repeat citation from the September 12, 2024 annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Will review induction process on 9/29/2025 during group supervision with updated guide sheets to follow when completing an admission. Can review any barriers staff face during monthly supervisions with supervisor.
Will update induction cheat sheets to provide to all staff on 9/29/2025 to follow when there is a new admission. Management will review once a week on a weekly basis on 100% of the intakes admitted the week prior to ensure documents are completed in a timely manner with all admissions. Upon any findings, staff will complete items by end of the day from notice. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician review the dosage levels at least twice a year in one of nine patient records reviewed.Patient #9 was admitted on August 17, 2020 and was active at the time of the inspection. The last dosage review that was documented in the patient record was completed on July 8, 2024.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Will review with all staff during group supervision on 9/29/2025 regarding 6 month and annual physical reviews with patients. Patients will be scheduled 30 days prior to their 6 month and annual date by counselors, front desk, nursing and or management team to ensure they are not overlooked and stay within compliance.
At this time Director has been monitoring patients to be seen to ensure their dosage reviews are not overlooked. Any overdue patients were contacted and scheduled beginning on 9/15/2025. Future appointments are being scheduled 30 days from their intake date. Director will monitor doctor's schedule daily to ensure they are being seen as well as documentation being completed. Director is tracking which patient was seen daily. |
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 facility failed to 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 in two of nine patient records reviewed.Patient #2 was admitted on September 17, 2024 and was active at the time of the inspection. There was no documentation that the facility 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 in the patient record.Patient #5 was admitted on January 24, 2025 and was discharged March 29, 2025. There was no documentation that the facility 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 in the patient record.This is a repeat citation from the September 12, 2024 annual licensing renewal inspections.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Training on transferring in and out regarding documentation will be reviewed with staff to ensure documentation is in their EMR and meets compliance on 9/29/25 during group supervision. Will develop a guide sheet for staff to follow when they are conducting an admission that is a transfer or transferring a patient to another site.
Management including clinical supervisor and director will monitor transfer in admissions during weekly intake audits and transfer outs day of completing discharge to ensure all items required are in their EMR. This will begin on 9/29/2025 upon review with team on the process. |
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 facility failed to document the results of an in-person initial intake physical examination within 14 days of a telehealth induction in one of one applicable patient records. Patient #1 was admitted on June 12, 2025 and was active at the time of the inspection. A telehealth induction was completed with the patient on June 12, 2025; however, an in person physical examination was not documented in the record within 14 days of the telehealth induction. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During group supervision on 9/29/2025 staff will be educated regarding when an induction is completed via telehealth, the patient is required to be scheduled within 14 days with an in person provider to complete a physical.
Management will conduct once a week on a weekly schedule of intake chart audits to review 100% of all telehealth admissions to ensure physicals are completed within their 14 day period. If one was not completed they will be scheduled on the next available day with an in house provider. |
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 a review of patient records, the facility failed to document the results of annual physical examinations given by the narcotic treatment program, which included an annual reevaluation by the narcotic treatment physician in two of nine patient records reviewed.Client #6 was admitted on January 2, 2024 and was active at the time of the inspection. The initial physical examination was completed by a physician on January 2, 2024 and the next annual physical examination was due no later than January 2, 2025; however, there was no annual physical examination documented in the patient record at the time of the licensing inspection.Patient #9 was admitted on August 17, 2020 and was active at the time of the inspection. An annual physical examination was completed by a physician on July 8, 2024 and the next annual physical examination was due no later than July 8, 2025; however, there was no annual physical examination documented in the patient record at the time of the licensing inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Will review with all staff during group supervision on 9/29/2026 about compliance regarding annual physical reviews with patients. Patients will be scheduled by counselors, front desk, nursing and or management team to ensure they are not overlooked and stay within compliance. In attempts to avoid becoming overdue will be completed 30 days prior to admission date.
Director has begun process with scheduling all overdue and upcoming annuals on 9/15/2025. Director will monitor daily doctor schedule to ensure providers are completing physicals with patients that are scheduled. If any are missed they will be flagged to be seen the next business day. This will be done every month to stay within compliance. Director will track 100% of annual physicals. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the facility failed to document a complete patient record with information relative to the patient's involvement with the project to include a psychosocial evaluation of the patient in one of nine patient records reviewed.Patient #5 was admitted on January 24, 2025 and was discharged March 29, 2025. A psychosocial evaluation was not documented in the patient ' s record at the time of the inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Will provide updated induction guide sheet for all staff to follow when conducting an new admission. Will review and re-educate induction process regarding intakes of all kinds including BPS during group supervision on 9/29/25.
Will update induction cheat sheets to provide to all staff to follow when there is a new admission. Will review updated induction sheets during group supervision on 9/29/25. Management will monitor the EMR for all inductions once a week on a weekly basis to review 100% of all admissions admitted the week prior to ensure all items are being completed in a timely manner to meet compliance. Any items missing will be completed by staff that are notified by end of the day from notification. |
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 client records, the project failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in five of nine records reviewed.Client #1 was admitted on June 12, 2025 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on June 12, 2025, indicated that the client was to receive four counseling sessions per month; however, there was only one counseling session documented for the month of July 2025.Client #2 was admitted on September 17, 2024 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on September 17, 2024, indicated that the client was to receive one individual session per month; however, there was only one individual counseling session documented in the client record for the months of October 2024, November 2024, December 2024, March 2025, April 2025, May 2025, June 2025 and July 2025.Client #4 was admitted on September 18, 2024 and was discharged July 18, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on October 24, 2024, indicated that the client was to receive one individual session per week; however, there were no individual counseling sessions documented in the client record for the weeks of November 17, 2024 through November 23, 2024, November 24, 2024 through November 30, 2024 and December 1, 2024 through December 7, 2024.Client #5 was admitted on January 24, 2025 and was discharged March 29, 2025. A comprehensive treatment and rehabilitation plan, documented in the client record on January 24, 2025, indicated that the client was to receive ten counseling sessions per month; however, there were only four counseling sessions documented for the month of February 2025. Client #6 was admitted on January 2, 2024 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on January 24, 2025, indicated that the client was to receive three group counseling sessions per month; however, there was only one group counseling session documented for the months of November 2024, January 2025, February 2025 and March 2025. Additionally, there were only two group sessions documented for the months of May 2025 and July 2025.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
During group supervision on 9/29/2025 will re-educate on prescribed counseling. Will review with staff on EMR profile and treatment plans to match as well as review appropriate prescribed time with patients. Will further review any barriers during individual supervisions.
Management including clinical supervisor and director will monitor prescribed counseling amongst caseloads daily when reviewing counseling hours completed. Will review in group supervision on 9/29/2025 about prescribed counseling needing to match in both profile and treatment plans as well as whether they are appropriate to the needs of the patient. |
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 a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information entered within 7 days, 30 days and 60 days of the client ' s discharge, per the facility's policy, in four out of four applicable records reviewed.Client #3 was admitted on June 27, 2023 and was discharged on October 6, 2024. There were no 7 day, or 30-day follow-up contact information documented in the client record at the time of the inspection.Client #4 was admitted on September 18, 2024 and was discharged July 18, 2025. There was no 7-day follow-up contact information documented in the client record at the time of the inspection.Client #5 was admitted on January 24, 2025 and was discharged March 29, 2025. There was no follow-up contact information documented in the client record at the time of the inspection.Client #7 was admitted on July 28, 2014 and was discharged October 23, 2024. There were no 7 day, or 30-day follow-up contact information documented in the client record at the time of the inspection.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff will be trained on procedures when a patient is discharged and what steps are taken regarding discharge follow up calls during group supervision on 9/29/25. A guide sheet will be given on procedures to follow upon discharging a patient as well as creating a tracking system for those that are discharged from program to ensure 7/30/60 post discharge follow up calls are completed.
Staff meeting will be held on 9/29/25 to review discharge follow up procedures. Clinical Supervisor will review each caseload weekly with counselors in supervision and review 100% of all discharges from the week prior with staff to ensure all required discharged follow ups are updated. Any not completed as of yet will be completed same day after notified from clinical supervisor. |