INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 16, 2026 through September 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 IX dba Hazelton Treatment Services 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
|
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
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 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 eight records reviewed.
Client #7 was admitted on November 3, 2025, and was active at the time of the inspection. The facility failed to obtain a release of information for the funding source, and it was verified that billing had occurred.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On 9/24/2026 a training was conducted with the clinical team on proper completion of authorization to release forms emphasizing confidentiality and DDAP 709.28 (c).
The clinical supervisor will conduct monthly record audits of no less than 10 charts inspecting for proper completion of the authorization to release forms. Clinical supervisor will review each release of information authorization to ensure that the correct information to be provided is included on the authorization.
New Release of Authorization/Consent is unable to be attained due to client discharging and no longer active at this facility. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
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 that included the specific information to be disclosed in four of eight client records reviewed.
Client # 3 was admitted on January 14, 2025, and was active at the time of the inspection. Three releases of information forms, one for a state agency and two for funding sources, signed by the client on February 10, 2026, did not specify the specific information to be disclosed.
Client #4 was admitted on May 4, 2026, and was discharged August 11, 2026. Two releases of information forms, one for a state agency and one for a probation office, signed by the client on May 4, 2026, did not specify the specific information to be disclosed.
Client #5 was readmitted on July 30, 2026, and was current at the time of the inspection. A release of information form for a state agency, signed by the client on July 30, 2026, did not specify the specific information to be disclosed.
Client #7 was admitted on November 3, 2025, and was active at the time of the inspection. A release of information form for a state agency, signed by the client on November 3, 2025, did not specify the specific information to be disclosed.
This is a repeat citation for the September 4, 2025, annual licensing inspection.
The findings were reviewed with project staff during the licensing process.
|
Plan of Correction
On 9/24/2026 a training was conducted with the clinical team on proper completion of authorization to release forms emphasizing confidentiality and DDAP 709.28 (c) (2) including checking appropriate boxes indicating what information is to be shared.
The clinical supervisor will conduct monthly record audits of no less than 10 charts inspecting for proper completion of the authorization to release forms. Clinical supervisor will review each release of information authorization to ensure that the correct information to be provided is included on the authorization.
New Releases of Information/Consent were created for each of the client's (3, 4, 5, and 7) that indicate what information is to be disclosed and appropriate boxes check on the releases. |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
|
Observations
Based on a review of client records, the facility failed to ensure that verbal orders were authenticated in writing by a physician or other medical professional within three business days from the time the order was given in one applicable record reviewed.
Client # 1 was admitted on July 10, 2023, and was discharged on June 29, 2026. Verbal orders were given on June 6, 2026, that were not authenticated in writing by an authorized provider until June 12, 2026.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Training & Education Efforts
1. Review of DDAP standard for verbal orders and required signatures with nurses, medical director, staff physician, nurse practitioner to be completed by 10/30/2026. 2. Medical staff will continue to attend bi-weekly provider meetings. 3. Nurses will attend monthly nursing professional development and training meetings.
1. Executive director will review DDAP standard for verbal orders and signatures in nursing supervision by and leadership meeting by 10/30/2026. 2. Staff physician(s) will review digital signing daily and ensure that all orders are signed within 3 business days after the order is given. 3. Executive director will check digital signing on a daily basis to ensure that all orders are signed in compliance with DDAP standard. |
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.
|
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 of two applicable records reviewed.
Client #8 was admitted on February 7, 2025, and was involuntarily discharged on December 30, 2025. 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.
|
Plan of Correction
The Project Director and Clinical Supervisor met with the Office Staff on 9/24/2026 and reviewed the Involuntary Termination policy. The Office Staff were informed that, even if a client is AWOL or current address unknown, a letter of involuntary termination will be sent to the last known address and a copy of such placed in the client file.
Facility will have Office Staff send out letter of involuntary discharge to client and upload into the client's chart. Clinical Supervisor and/or Executive Director will review and notate in chart that review was completed and letter uploaded. |
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.
|
Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent was administered in one of eight records reviewed.
Patient #5 was admitted on July 30, 2026, and was active at the time of inspection. There was no informed, voluntary, written consent documented in the record before an agent was administered.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Staff were re-educated on the intake process during the Monthly Staff meeting on 10/8/2026. During this review an emphasis was placed on §715.12(1-5) specifically regarding the requirement that no narcotic agent may be administered prior to obtaining the informed voluntary written consent, without exception. Additional training and education will be completed by 12/31/2026 for all medical and nursing staff to review all new admissions, ensuring the Patient Informed Voluntary Written Consent is signed prior to the Patient's initial dose. As part of the Chart Audit process on site, the Clinical Supervisor or Program Director will review all new admissions within 24 hours to ensure Pt. informed voluntary written consent is in the record and compliance to same. The Clinical Supervisor and Clinic Director will continue with monthly Chart Audits of all admissions to ensure sustained compliance with §715.12(1-5). |
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.
|
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 two of eight records reviewed.
Patient #1 was admitted on July 10, 2023, and was discharged on June 29, 2026. Only one dosage review was documented in the patient record for the 2025 treatment year.
Patient #7 was admitted on November 3, 2025, and was active at the time of the inspection. No dosage reviews were not documented in the patient record for the 2025 and 2026 treatment years.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The narcotic treatment physicians 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. Director will generate and monitor reports using the electronic health records system monthly and schedule patients for therapeutic dosage checks with physicians at least twice a year. Therapeutic dosage checks will be documented in the patients record. |
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.
|
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 three of eight records reviewed.
Client # 1 was admitted on July 10, 2023, and was discharged on June 29, 2026. A comprehensive treatment and rehabilitation plan update documented in the client record on September 30, 2025, indicated that the client was to receive two individual or group counseling sessions per month; however, there was only one counseling session documented in the record for the months of October 2025, January 2026, February 2026 and May 2026.
Client #2 was admitted on March 18, 2025, and was a current client at the time of the inspection. A comprehensive treatment and rehabilitation plan update documented in the client record on September 16, 2025, indicated that the client was to receive two individual or group counseling sessions per month; however, there was only one counseling session documented in the record for the months of October 2025, February 2026, March 2026, May 2026 and June 2026.
Client # 3 was admitted on January 14, 2025, and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan update documented in the client record on August 11, 2025, indicated that the client was to receive two individual or group counseling sessions per month; however, there was only one counseling session documented in the record for the months of October 2025, December 2025, January 2026 and March 2026.
This is a repeat citation for the September 4, 2025, annual licensing inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor met with all staff on 10/8/2026 and received re-education emphasizing that each client must receive counseling services in accordance with their individualized treatment plan. Counseling staff will review the Monthly Requirements Report to ensure that all Patients are receiving the correct amount of counseling hours designate on the report. Staff will be reminded to consistently utilize this report as a reference to support compliance. The Quality Improvement Department will conduct random chart reviews to verify adherence to regulatory requirements and to ensure documentation accurately reflects any changes to the type or frequency of services provided. |
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.
|
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 three out of three applicable records reviewed.
Client #1 was admitted on July 10, 2023, and was discharged on June 29, 2026. There was no 7 day, 30-day or 90-day follow-up contact information documented in the client record at the time of the inspection.
Client #4 was admitted on May 4, 2026, and was discharged on August 17, 2026. There was no 7-day follow-up contact information documented in the client record at the time of the inspection.
Client #8 was admitted on February 7, 2025, and was discharged on December 30, 2025. There was no 30-day, and 90-day follow-up contact information documented in the client record at the time of the inspection.
This is a repeat citation for the September 4, 2025, annual licensing inspection.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Counseling staff will receive a training on 10/29/2026 to review 709.93(a)(11) LICENSURE, Client records, Follow-up information. This will include the process, completion, and documentation of 7/30/60 day follow-up calls.
The clinical supervisor will conduct monthly record audits of no less than 10 charts to ensure that follow-up information, including telephone calls, are being completed in accordance with facility policy and state regulation. Clinical supervisor will use a report to identify discharged clients that require follow-up information. Counselors will properly document in the patient chart all follow-up attempts and outreach. |