INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 28-30, 2025, 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-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
Charleroi Treatment Service's Executive 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 the upcoming 10/9/2026 staff meeting and Clinical Supervisor reviewed in 9/23/2026 clinical meeting.
The Project Director will review and ensure policies are updated and issue a signed attestation to that effect by January 15th, 2027. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of medical staff coverage, the facility failed to provide narcotic treatment physician services for at least 1 hour per week onsite for every ten patients in one of seventeen weeks.Physician service hours were reviewed from May 3, 2026, through August 29, 2026. For the week of June 14, 2026, through June 20, 2026, the facility's census was 333 patients. The facility was required to provide 33.3 hours of onsite physician services; however, the physician hours totaled 22.75 hours.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director and Medical Director reviewed physician schedules, secured additional physician coverage, and established a backup coverage plan to address anticipated absences or staffing shortages. Regulatory staffing requirements were reviewed with prescribing providers and scheduling personnel. Effective immediately, the Executive Director will complete and document a weekly comparison of patient census, required physician hours, scheduled physician hours, and actual onsite physician hours. Any anticipated or identified shortfall will be addressed immediately through schedule adjustment or activation of backup coverage. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of medical staff coverage, the facility failed to ensure one-third of all required narcotic treatment physician time was provided by a narcotic treatment physician in one of eighteen weeks.Physician service hours were reviewed from May 3, 2026, through August 29, 2026. For the week of June 14, 2026, through June 20, 2026, the facility's census was 333 patients. The facility was required to provide 33.3 hours of onsite physician services. One-third of 33.3 is 11.1. The narcotic treatment physician hours should have been 11.1 hours; however, the physician hours totaled 7.25 hours.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director has implemented a physician staffing tracking tool to monitor physician and CRNP coverage hours monthly. A monthly staffing ratio audit will be conducted to verify that physician coverage remains at or above the required one-third threshold. Clinical leadership staff and scheduling personnel will receive training regarding physician staffing requirements, delegated duties, and documentation expectations. Any staffing changes affecting physician coverage will be reviewed by the Executive Director and Medical Director prior to implementation. This will be addressed during our staff meeting on 10/13/2026. |
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 a review of patient records, the facility failed to have a narcotic treatment physician determine the patient 's initial dose and schedule in one of three applicable records.Patient #2 was admitted on April 28, 2026, and was still active at the time inspection. An initial dose order was documented by the CRNP on April 28, 2026.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, all initial medication orders will be determined, documented, and signed by our Medical Director before the first dose is administered. A CRNP may assist with assessment and documentation within the scope of delegated duties but will not independently determine the initial dose.
On October 16th, 2026, the Medical Director alongside the Executive Director will educate CRNP and nursing staff with initial-dose requirements and the prohibition against administering an initial dose without a physician-authenticated order. Nursing staff will verify the physician's signature before administration. The Executive Director will audit 100% of new admissions to confirm that the initial dose was signed by the medical director before administration. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient in two of two records. Patient #4 was admitted on July 15, 2025, and discharged on December 8, 2025. There was no documentation of any transfer paperwork being sent.Patient #6 was admitted on February 1, 2021, and discharged on July 20, 2026. A fax was sent to the receiving facility and did not include a medical summary.These findings was reviewed with the facility staff during the licensing process. This is a repeat citation from October 28-30, 2025, licensing inspection.
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Plan of Correction
Charleroi Treatment Services Clinical Supervisor will review process of sending correct patient information to a facility they are transferring to in the upcoming 10/13/2026. Clinical and all Staff Meeting. It will be reviewed that Charleroi Treatment Services will transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests and status of the patient and shall contain written consent of the patient. Ongoing individual and group supervision will address progress in the process of sending above outlined patient records to a facility a patient is transferring to meet standards and regulations. Individual and group supervision is being followed will be the responsibility of the Executive Director and Clinical Supervisor.
(1) The Executive Director will ensure plans of correction are implemented by the corrective action date and the clinical supervisor will assist in monitoring the process (2) The Clinical Supervisor will address CTS will transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests and current status of the patient and shall contain written consent of the patient in the 10/13/2026 Clinical and all Staff Meeting, (3) Executive Director will address and enforce the same information in the same all staff meeting, (4) Monthly individual supervision will address sending the above information for patients that transfer to other facilities (5) Individual patient charts will be reviewed during some individual supervision sessions, (6) Executive Director will review each patient chart that is being discharged to ensure above information is being sent to facilities the patient may be transferring to (7) Executive Director and the Clinical Supervisor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process.(8)Executive Director will also keep an excel spreadsheet listing all transferred in/out patient list for record. |
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 include the results of an annual physical examination by the narcotic treatment physician in one of two applicable records.Patient #6 was admitted on February 1, 2021, and discharged on July 20, 2026. The annual physical was due no later than February 1, 2026; however, it was completed on February 4, 2026.This finding was reviewed with the facility staff during the licensing process. This is a repeat citation from October 28-30, 2025, licensing inspection.
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Plan of Correction
The Executive Director, Medical Director and CRNP will review all active patient records to ensure annual physical examinations were current and scheduled within required regulatory timeframes. Charleroi Treatment Services will establish an enhanced tracking system to monitor annual physical examination due dates, which is reviewed monthly by Executive Director, Clinical Supervisor and nursing staff. Patients with annual physical examinations due within the next 60 days are identified and scheduled in advance to ensure timely completion. In addition, the Executive Director, nursing staff, and Medical Director will receive re-education regarding regulatory requirements for annual physical examination timeframes and documentation standards. To provide ongoing oversight, the annual physical examination monitoring process has been incorporated into the facility's Quality Assurance and Performance Improvement program. The Executive Director will conduct monthly audits of annual physical examination due dates for all active patients for a period of twelve (12) months. Executive Director will ensure all physical examinations are on the schedule for the appropriate patient, monthly to ensure none are skipped or overdue. This will also be addressed in the upcoming all staff meeting on 10/30/2026. |
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, the facility failed to document follow-up information in four of four applicable records.The facility's policy and procedures state follow-up attempts will occur for all discharged patients, at a minimum of 7-days, 30-days and 60-days post discharge. Client #4 was admitted on July 15, 2025, and discharged on December 8, 2025. There was no 30 or 60-day follow-up in the record.Client #5 was admitted on May 16, 2025, and discharged on August 6, 2026. The 7-day follow-up was due no later than August 13, 2026; however, it was completed on August 27, 2026. The 30-day follow-up was due no later than September 6, 2026; however, it was completed on September 8, 2026. Client #6 was admitted on February 1, 2021, and discharged on July 20, 2026. The 7-day follow-up was due no later than July 27, 2026; however, it was completed on July 31, 2026. The 30-day follow-up was due no later than August 20, 2026; however, it was completed on August 27, 2026. The 60-day follow-up was due no later than September 20, 2026; however, it was not completed.Client #7 was admitted on October 5, 2020, and discharged on November 25, 2025. There was no follow-up documented. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the October 28-30, 2025, licensing inspection.
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Plan of Correction
Charleroi Treatment Services Clinical Supervisor will review the process of timely completion of the discharge follow-up procedures in upcoming 10/13/2026 Clinical and all Staff meetings. It will be reviewed that discharge follow-ups must be completed and signed in a timely manner for each 7-day follow-up, 30-day follow-up, and 60-day follow-up. Giving the opportunity for education and what tools are accessible to each party involved.
Executive Director will have ongoing individual discussions with Clinical Supervisor and address timely completion of each follow-up to meet standards and regulations. (1) The Executive Director will ensure plan of corrections are implemented by the corrective action date with Clinical Supervisor will assist in monitoring the process (2) Clinical Supervisor will address that Charleroi Treatment Services will complete all follow ups in a timely manner in the 10/13/2026 Clinical staff meeting, and Executive Director will address the same information in the 10/13/20265 staff meeting, (3) Executive Director will review patient chart audits and review findings with Clinical Supervisor to ensure all follow ups are being completed in a timely manner (4) Executive Director will address Clinical Supervisor with any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process. |