INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 24-25, 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-III, 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:
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Plan of Correction
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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.
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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.
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Plan of Correction
The Project Director will review and ensure policies are updated and issue a signed attestation to that effect by January 15, 2027. |
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 a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one applicable record.Client #6 was admitted to the outpatient level of care on June 2, 2025, and discharged on May 8, 2026.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and ED met on
9/28/26 and reviewed the procedures when a patient is discharged involuntarily.
Clinical supervisor and ED will
monitor all discharges to ensure that the procedures are followed.
Clinical Supervisor and ED reviewed the regulation and procedure with the clinical staff during the clinical staff meeting on 10/8/26. Clinical staff were made aware that patients must be notified in writing of a decision to involuntarily terminate the patient's treatment. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every sixty days in four of seven records.Client #2 was admitted to the outpatient level of care on November 4, 2025, and was still active at the time of the inspection. A treatment plan update was completed on January 13, 2026, and the next update was due no later than March 13, 2026; however, it was completed on March 17, 2026. Another treatment plan update was completed on July 3, 2026, and the next update was due no later than September 3, 2026; however, it was completed on September 4, 2026.Client #3 was admitted to the outpatient level of care on June 23, 2026, and was still active at the time of the inspection. A treatment plan was developed on July 3, 2026, an update was due no later than September 3, 2026; however, there were no further updates in the record. Client #6 was admitted to the outpatient level of care on June 2, 2025, and discharged on May 8, 2026. A treatment plan update was completed on February 3, 2026, and the next update was due no later than April 4, 2026; however, it was completed on April 7, 2026. Client #7 was admitted to the outpatient level of care on May 22, 2020, and discharged on March 18, 2026. A treatment plan update was completed on December 22, 2025, and the next update was due no later than February 22, 2026; however, it was completed on March 9, 2026.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from October 20-22, 2025, licensing inspection.
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Plan of Correction
Clinical Supervisor and ED met with the clinical staff on 10/8/26 during the group clinical supervision regarding documenting treatment plan updates every 60 days. This will be an ongoing discussion in monthly group supervision.
Individual supervision will also address documenting treatment plan updates every 60 days.
Internal tracking tools will be utilized to ensure that treatment plan updates are completed within the 60 day requirement. Clinical staff have independent trackers that they review in individual supervisions. Trackers are built in to the EHR are monitored by ED and clinical supervisor daily to comply with due dates of treatment plan updates.
Ensuring the POC will be followed will be the responsibility of the Director and the Clinical Supervisor.
Supervisor and Lead Counselor will address and any issues with non compliance in this area and discuss any additional training or focus that is required to improve the process. |