INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 16-17, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pinnacle Treatment Centers PA-V, LLC, 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:
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors who did not function for 2 years as a supervisor in the provision of clinical services completed a Department approved core curriculum in clinical supervision in one of one applicable record.
Staff #3 was hired as clinical supervisor on September 28, 2025, and was still in the position at the time of inspection. There was no documentation of clinical supervision experience prior to being hired, and the clinical supervision training was not completed until September 17, 2026.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisor completed an approved alternative to DDAP's clinical supervisor training on 9/17/26. Clinical Supervisor will continue to receive individual and group supervision from Executive Director and Regional Clinical Director.
Upon hire of a new clinical supervisor, during the initial training period, there will be a schedule to complete all trainings with in the first six months of hire and completion will be monitored monthly during supervision by the Executive Director. Certificates will remain on file on site to be presented during the yearly DDAP audit to ensure compliance. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on a review of administrative documents, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
The last documented sign-off from the project director was dated January 15, 2025, and the next one was due no later than January 15, 2026; however, the documentation provided was dated August 11, 2026, and signed by the compliance specialist. When the document was reviewed with the project director, their signature was also added on to the document.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director will review the nature and background for the need of annual update and the need of sign-off of the written manual delineating project policies and procedures in upcoming 10/8/26 Staff Meeting and Clinical Supervisor will review in 10/19/26 clinical meeting.
The Project Director will review and ensure policies are updated and issue a signed attestation to that effect by January 15, 2027. |
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.
|
Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one of seven applicable records.
Client #1 was admitted on January 9, 2026, and discharged on September 8, 2026. There was no consent to release information form for the funding source in the record. Facility staff confirmed billing had occurred.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the September 17-19, 2025, licensing inspection.
|
Plan of Correction
Complete training on completion of consents to include all specific information to be disclosed. Training conducted on 9/30/26. All onboarding education for new hires includes confidentiality modules to reinforce confidentiality requirements.
Counselors will complete the voluntary consent form in its entirety, checking that all information including to whom is included in the document. Clinical Supervisor will conduct regular chart audits including a review of consent forms to ensure that they are accurately completed and regularly report findings to Executive Director and Regional Director. Quality Director will check six charts quarterly to ensure consents are completed accurately. Summary of findings is sent to Executive Director and Clinical Supervisor to review with staff as a training opportunity. Compliance officer will complete quarterly billing audits and share findings regarding completion of consent forms. |
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.
|
Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician determine the patient 's initial dose and schedule in three of three applicable records.
Patient #1 was admitted on January 9, 2026, and discharged on September 8, 2026. An initial dose order was documented by the CRNP on January 9, 2026.
Patient #2 was admitted on January 20, 2026, and discharged on June 8, 2026. An initial dose order was documented by the CRNP on January 20, 2026.
Patient #3 was admitted on April 17, 2026, and was still active at the time of inspection. An initial dose order was documented by the CRNP on April 17, 2026.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Re-training on writing all medication orders to ensure that the dose and rationale are appropriate. All orders will be countersigned by medical director. Re-training will occur during medical weekly call on 10/29/26 and also the Aliquippa staff meeting on 10/29/26.
Quality director will review six charts each quarter to ensure all orders align with the standard. Compliance will provide quarterly billing audits to ensure all orders are properly signed. |