INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 27, 2025 through October 28, 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in four of eleven applicable personnel records reviewed.
Employee #7 was hired as a counselor on January 16, 2024 and was due to have the HIV/AIDS training and the TB/STD training no later than January 16, 2024. There was no documentation in the record indicating the TB/STD training was completed as of the date of the inspection.
Employee #11 was hired as a counselor on May 22, 2023 and was due to have the HIV/AIDS training and the TB/STD training no later than May 22, 2024. There was no documentation in the record indicating both the TB/STD training and the HIV/Aids training were completed as of the date of the inspection.
Employee #23 was hired as a engagement specialist on April 11, 2022 and was due to have the HIV/AIDS training and the TB/STD training no later than April 11, 2024. There was no documentation in the record indicating the TB/STD training was completed as of the date of the inspection.
Employee #24 was hired as a engagement specialist on May 23, 2022 and was due to have the HIV/AIDS training and the TB/STD training no later than May 23, 2024. There was no documentation in the record indicating the TB/STD training was completed as of the date of the inspection.
This is a repeat citation from the October 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. All current staff identified in the deficiency who do not have the required HIV/AIDS and TB/STD trainings will be required to complete the trainings through DDAP based on available seats by 2/28/26. Upon completion, The Program Director will upload proof of training into Merakey's learning management system (LMS).
2.The Executive Director will collaborate with other Merakey SUD/MAT programs requiring these trainings to develop and implement an internal training curriculum that meets regulatory requirements. The Executive Director will submit the newly developed internal curriculum to the Department for approval prior to implementation.
3. Executive Director will collaborate with other internal SUD programs to develop a curriculum for HIV and TB/STD training that meets DDAP requirements. Once a curriculum is approved internally, the Executive Director will submit the proposed curriculum to DDAP for review and approval. Once approved by DDAP, the program will add the curriculum into staffs training plan.
4. Monitoring: The Program Director will continue to monitor staff trainings using an internal tracking spreadsheet and Merakey's Learning Management System (LMS) monthly. If any trainings are found to be out-of-date, the Program Director will send email reminds to staff to complete the trainings as soon as possible. If trainings are not completed by the identified deadline, he Program Director will begin the progressive discipline progress with Human Resources. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training during the facility's July 1, 2024 through June 30, 2025 training year in six of nine applicable personnel records reviewed.
Employee #6 was hired as a counselor on January 8, 2024. The personnel record documented 9 hours and 52 minutes of training received during the training year reviewed.
Employee #7 was hired as a counselor on January 16, 2024. The personnel record documented 9 hours of training received during the training year reviewed.
Employee #10 was hired as a counselor on January 9, 2023. The personnel record documented 15 hours and 30 minutes of training received during the training year reviewed.
Employee #11 was hired as a counselor on May 22, 2023. The personnel record documented 1 hours and 20 minutes of training received during the training year reviewed.
Employee #12 was hired as a counselor on June 26, 2023. The personnel record documented 7 hours and 5 minutes of training received during the training year reviewed.
Employee #17 was hired as a counselor on October 6, 2003. The personnel record documented 4 hours of training received during the training year reviewed.
This is a repeat citation from the December 5, 2023 and October 18, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Program Director will review required training hours with all staff at the next group supervision in December. This review will be documented.
2. Moving forward, the Program Director will continue to monitor all staff's progress to completing the required 25 clock hours for the FY26 training plan using an internal tracking spreadsheet and Merakey's Learning Management System (LMS) monthly. If any trainings are found to be out-of-date, the Program Director will send email reminders to staff to complete the required trainings by an identified due date.
3. Monitoring: The Program Director will review ongoing training hours with staff during individual supervision. If trainings are not completed by the identified deadline, the Program Director will begin the progressive discipline progress with Human Resources. |
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 a review of personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment in eight of nine applicable personnel records reviewed.
Employee #3 was hired as a clinical supervisor on December 16, 2024. There was documentation in the personnel record indicating the fire extinguisher training was completed on October 1, 2025.
Employee #8 was hired as a counselor on April 14, 2025. There was no documentation in the personnel record indicating the fire extinguisher training was completed as of the date of the inspection.
Employee #15 was hired as a counselor on August 18, 2025. There was documentation in the personnel record indicating the fire extinguisher training was completed on September 24, 2025.
Employee #18 was hired as a nurse on April 7, 2025. There was documentation in the personnel record indicating the fire extinguisher training was completed on October 1, 2025.
Employee #19 was hired as a physician on June 30, 2025. There was documentation in the personnel record indicating the fire extinguisher training was completed on September 24, 2025.
Employee #20 was hired as a medical supervisor on April 30, 2025. There was documentation in the personnel record indicating the fire extinguisher training was completed on October 2, 2025.
Employee #21 was hired as a physician on July 7, 2025. There was documentation in the personnel record indicating the fire extinguisher training was completed on September 24, 2025.
Employee #22 was hired as a case manager on July 28, 2025. There was documentation in the personnel record indicating the fire extinguisher training was completed on September 24, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Program Director met with the Administrative Assistant on 11/7/25 to train on fire safety requirements and utilizing the fire safety PowerPoint with all new staff.
2. Beginning on 12/1/25, the Administrative Assistant will begin training all new staff members on the use of fire extinguishers during new hire orientation and training, and send all documentation of the training to the Program Director to add to the staff member's Personnel File.
2. The Program Director updated the New Hire Checklist to include all fire safety requirements and documents needed. This will be completed by the Administrative Assistant and Supervisors.
3. Monitoring: The Program Director will review each new staff member's completed checklists. If an area is identified missing, Program Director will assign immediately for completion.
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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 review of personnel records, the facility failed to ensure all personnel were trained to perform assigned tasks during emergencies in eight of nine applicable personnel records reviewed.
Employee #3 was hired as a clinical supervisor on December 16, 2024. There was documentation in the personnel record indicating the employee was trained to perform assigned tasks during emergencies on October 1, 2025.
Employee #8 was hired as a counselor on April 14, 2025. There was no documentation in the personnel record indicating the employee was trained to perform assigned tasks during emergencies as of the date of the inspection.
Employee #15 was hired as a counselor on August 18, 2025. There was documentation in the personnel record indicating the employee was trained to perform assigned tasks during emergencies on September 24, 2025.
Employee #18 was hired as a nurse on April 7, 2025. There was documentation in the personnel record indicating the employee was trained to perform assigned tasks during emergencies on October 1, 2025.
Employee #19 was hired as a physician on June 30, 2025. There was documentation in the personnel record indicating the employee was trained to perform assigned tasks during emergencies on September 24, 2025.
Employee #20 was hired as a medical supervisor on April 30, 2025. There was documentation in the personnel record indicating the employee was trained to perform assigned tasks during emergencies on October 2, 2025.
Employee #21 was hired as a physician on July 7, 2025. There was documentation in the personnel record indicating the employee was trained to perform assigned tasks during emergencies on September 24, 2025.
Employee #22 was hired as a case manager on July 28, 2025. There was documentation in the personnel record indicating the employee was trained to perform assigned tasks during emergencies on September 24, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Program Director met with the Administrative Assistant on 11/7/25 to train on fire safety and emergency procedure requirements. We will utilize the fire safety PowerPoint with all new staff.
2. Beginning on 12/1/25, the Administrative Assistant will begin training all new staff members on the use of fire extinguishers and emergency procedures during new hire orientation and training then send all documentation of the training to the Program Director to add to the staff member's Personnel File.
3. The Program Director updated the New Hire Checklist to include all fire safety and emergency procedure requirements and documents needed. This will be completed by the Administrative Assistant and Supervisors.
4. Monitoring: The Program Director will review each new staff member's completed checklists. If an area is identified missing, Program Director will assign immediately for completion.
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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 a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #4 was admitted on January 7, 2025 and was discharged on January 29, 2025. There was documentation of disclosures to the funding source during the client's treatment episode; however, the consent to release information was not finalized nor entered into the facility's electronic medical record until October 27, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Program Director retrained the Intake Supervisor on the responsibilities of obtaining valid Releases of Information/Form for each client upon admission to the program, including to the client's funding source, on 11/10/25.
2. The ABH Operations Coordinator will update the Intake Monitoring Tool to include a review of Releases of Information, including to the client's funding source.
3. The Intake Supervisor will audit all paperwork weekly utilizing the Intake Monitoring Tool to ensure releases of information are present and finalized in the client's record.
4. Monitoring: The Program Director will discuss a sample of completed Intake Monitoring Tools with the Intake Supervisor during monthly individual supervision. This review will be documented as a supervision note. |
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 the individual's identity, which is to include the name, address, date of birth, emergency contact, and other identifying data, prior to the administration of an agent in one of six applicable patient records reviewed.
Patient #4 was admitted on January 7, 2025 and discharged on January 29, 2025. The patient's emergency contact was not finalized nor entered into the electronic medical record until October 27, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Program Director retrained the Intake Supervisor on verifying the client's identity prior to admission to the program on 11/10/25.
2. The ABH Operations Coordinator will update the Intake Monitoring Tool to include a review of identity verification, including name, address, date of birth, and emergency contact, etc.
3. The Intake Supervisor will audit all paperwork weekly utilizing the Intake Monitoring Tool to ensure there is evidence of identify verification in the client's record.
4. Monitoring: The Program Director will discuss a sample of completed Intake Monitoring Tools with the Intake Supervisor during monthly individual supervision. This review will be documented as a supervision note. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the medication unit's physical plant inspection conducted on October 28, 2025 from 8 a.m. to 8:45 a.m., the facility failed to ensure administering and dispensing of medication would be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
The medication unit's dispensing window is located directly adjacent to a main hallway, where at the time of the inspection, multiple individuals not related to the medication unit were walking through the hallway. At the time of the inspection, there was no privacy protection from disruption or annoyance for the patients receiving medication.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. As of 12/2/25, the facility will implement temporary privacy measures to ensure dispensing station privacy and confidentiality which will include:
- Limiting access and traffic to the dispensing area by closing off entrances to main hallways surrounding the dispensing booth.
- Putting up temporary privacy partitions during the dispensing hours of operation
- Assigning a security guard (staff) to the dispensing area, which will ensure that only one person is in the booth at a time
- Security guard (staff) monitoring hallways to ensure no disruption and increased privacy
- Posting signage that states only one person in dispensing area at a time
These measures will be put in place immediately, until a more permanent plan can be established.
2. The Executive Director sent an email communication to the Department in November to better understand possible solutions. Additionally, Merakey Leadership has been made aware and is working to finalize a plan for a permanent update to the dispensing window. Options include a permanent privacy divider surrounding the dispensing area or adjustment of patient dosing schedules to reduce/control access to dispensing area. Plan will be completed by 1/1/2026. |
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 narcotic treatment program failed to document in writing that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in three of four applicable patient records reviewed.
Patient #4 was admitted on January 7, 2025 and was discharged on January 29, 2025. The patient record did not include documentation indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #6 was admitted to the medication unit on October 23, 2025 and was active at the time of the inspection. The patient record did not include documentation indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #7 was admitted to the medication unit on October 15, 2025 and was active at the time of the inspection. The patient record did not include documentation indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
This is a repeat citation from the October 18, 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 Program Director re-educated the Intake Supervisor in individual supervision in November on the appropriate procedures when admitting a transferred client. This review is documented.
2. When accepting a transferred client from another program, the Intake Supervisor will provide a Letter of Acceptance to the transfer clinic that includes the date of admission of the patient's admission and the date of the initial dose given to the patient. This form will be completed via paper and uploaded in client's EHR during the intake process.
3. The ABH Operations Coordinator will add a review of the Letter of Acceptance to the Intake Monitoring Tool for the Intake Specialist to complete.
4. Monitoring: The Program Director will discuss a sample of completed Intake Monitoring Tools with the Intake Supervisor during monthly individual supervision. This review will be documented as a supervision note. |
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 also reviewed, dated, and signed by the medical director in one of one applicable patient records reviewed.
Patient #3 was admitted on September 1, 2015 and was discharged on April 23, 2025. The last annual evaluation of the patient's status was completed by the counselor on August 31, 2023. There was no 2024 annual evaluation completed prior to discharge.
This is a repeat citation from the October 18, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. All staff have access to a treatment planning tracker that tracks and monitors upcoming documentation due dates, including due dates for client's annual evaluations.
2. The ABH Operations Coordinator will collaborate with the Senior Systems of Care Manager to add the Annual Client Evaluation form to an existing internal dashboard that assists staff in tracking time sensitive documentation.
2. Monitoring: The Clinical Supervisor will monitor annual assessment due dates using the treatment planning tracker and review upcoming due dates with staff through individual supervision and address barriers to completion, as necessary. The Clinical Supervisor will engage in progressive discipline with staff, as necessary. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to ensure counselors completed 25 hours of annual training was submitted and approved by the Department for the December 5, 2023 and October 18, 2024 annual licensing inspections. Failing to ensure counselors completed 25 hours of annual training was again found to be a deficiency in the October 27, 2025 through October 28, 2025 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Executive Director reviewed the Plan of Correction (POC), emphasizing repeat citations, with the Program Director and the expectations to continue to follow through on any plan of correction submitted to an external entity on 11/3/25 . This review is documented.
2. The Program Director reviewed the Plan of Correction (POC) with all program staff during the November staff meeting with an emphasis on repeat citations. This review is documented.
3. Merakey's Quality and Compliance Organization (QCO) elevated the repeat citations through Merakey's internal Notification of Risk procedure to provide program leadership with additional resources and support through the Plan of Correction (POC) development process.
3. Monitoring: Beginning on 12/1/25, the ABH Operations Coordinator will provide bi-monthly support to program leadership with the implementation of the POC and will assist the program with identifying any barriers to POC implementation. Barriers would be discussed at local performance and quality improvement (LPQI) meetings if applicable. |