INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 3, 2025 through September 4, 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 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:
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from October 2024 through August 2025, the facility failed to conduct an unannounced fire drill during the months of April 2025 and May 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Training Safety and Fire Drill Protocol was reviewed on 9/16/2025 to ensure all fire drills are properly documented. Reviewed protocol for unannounced drills.
Executive Director and Clinical Supervisor will monitor monthly for ongoing compliance. Fire drills will be completed once per month and will be documented for review. |
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.
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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 one of nine client records reviewed.
Client #6 was admitted on January 14, 2025 and was discharged August 27, 2025. A release of information form for the funding source, signed by the client on January 14, 2025, did not specify the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/18/2025 a training was conducted with the clinical team on proper completion of authorization to release forms emphasizing confidentiality and DDAP 709.28 (c) (2), (3), and 709.28 (d).
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. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the project failed to offer a copy of the release of information forms in one of nine client records reviewed.
Client #8 was admitted on August 1, 2025 and was a current client at the time of the inspection. There was no documentation that the client was offered a copy of the release of information form for the funding source; signed and dated by the client on August 1, 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 9/18/2025 a training was conducted with the clinical team on proper completion of authorization to release forms emphasizing confidentiality and DDAP 709.28 (c) (2), (3), and 709.28 (d).
Client and staff were able to review and complete the release of information form the including accept/reject portion. Client rejected a copy of the release of information at that time.
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 verify that there has been properly documented a release of information authorization for the funding source for the client. |
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 a patient ' s identity, which included the name, address, date of birth, emergency contact and other identifying information prior to the administration of an agent in one of nine patient records reviewed.
Patient #8 was admitted on August 1, 2025 and was a current patient at the time of the inspection. There was no documentation of the patient ' s emergency contact prior to the administration of an agent.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff will receive a training on 10/9/2025 to review 715.9(a)(2) LICENSURE including the necessity to obtain emergency contact information.
Patient shared that at time of intake she did not have an emergency contact. Counselor is working with Patient to identify an emergency contact and will update and complete a release of information for one upon next visit.
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 ensure that an emergency contact has been properly documented within the Patient chart and that a valid release of information authorization has been completed.
If no emergency contact is available, the clinician will notate in the progress note that the Patient does not have an emergency contact at that time. Clinical Supervisor will review this progress note. If Patient later provides emergency contact information an appropriate ROI will be created and signed and progress note will reflect this. |
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 facility failed to 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 in one of nine patient records reviewed.
Patient #8 was admitted on August 1, 2025 and was a current patient at the time of the inspection. There was no documentation that the facility 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 in the patient record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff will receive a training on 10/9/2025 to review 715.20(4) LICENSURE Patient transfers including completing and transmitting the Transfer Acknowledgement Form.
The clinical supervisor will conduct monthly record audits of no less than 10 charts inspecting for proper completion and transmittal of the Transfer Acknowledgement Form in the Patient's chart for patients that have transferred in their MAT services. Clinical supervisor will also collaborate with nursing staff to ensure all transfer criteria has been met and documented. |
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 document the results of annual physical examinations given by the narcotic treatment program, which included an annual reevaluation by the narcotic treatment physician in two of nine patient records reviewed.
Patient #5 was admitted on March 26, 2024 and was active at the time of the inspection. The record contained a physical dated March 26, 2024; there was no documentation that an annual physical was completed at the time of the licensing inspection.
Patient #9 was admitted on February 17, 2022 and was discharged on March 24, 2025. The last physical documented in the record was dated January 31, 2024; there was no documentation that an annual physical was completed at the time of the licensing inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff will receive a training on 10/9/2025 to review 715.23(b)(5) LICENSURE Patient records and review the protocol for ensuring that Patients receive their annual physical in a timely manner.
Patient #5 has been scheduled for an annual physical/re-evaluation with the medical director.
The executive director and clinical supervisor will conduct monthly record audits of no less than 10 charts inspecting for scheduling and completion of annual physicals for patients. Clinical supervisor will review monthly reports and dashboards to identify patients that are due or coming due for their annual physicals and ensure they are properly scheduled with a provider to have the annual physical completed. |
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.
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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 four of nine records reviewed.
Client #1 was admitted on February 7, 2025 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on March 7, 2025, indicated that the client was to receive two counseling sessions per month; however, there was only one counseling session documented for the months of April 2025 and August 2025.
Client #2 was admitted on May 8, 2025 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan, documented in the client record on May 24, 2025, indicated that the client was to receive two counseling sessions per month; however, there were no counseling sessions documented for the months of July 2025 and August 2025.
Client #5 was admitted on March 26, 2024 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan update, documented in the client record on October 18, 2024, indicated that the client was to receive two counseling sessions per month; however, there was only one counseling session documented for the months of April 2025 and May 2025. Additionally, there were no counseling sessions documented for the months of July 2025 and August 2025.
Client #7 was admitted on September 22, 2022 and was active at the time of the inspection. A comprehensive treatment and rehabilitation plan update, documented in the client record on October 19, 2024, indicated that the client was to receive one counseling session per month; however, there were no counseling sessions documented for the months of May 2025, July 2025 and August 2025.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff will receive a training on 10/9/2025 to review 709.92(c) LICENSURE, Treatment and rehabilitation service. This training and review will focus on the need to provide and properly document how the facility is meeting the patient's prescribed treatment time.
The clinical supervisor will conduct monthly record audits of no less than 10 charts to ensure that counseling services are provided according to the individual treatment and rehabilitation plan. Beginning 10/1/24 the clinical supervisor will meet with each counselor on at least a monthly basis to review patient monthly requirements and ensure any patient who has not met their requirements is scheduled to complete them. This information will also be included in the counselor's supervision. The clinical supervisor will meet with the director to review these results and assess for any obstacles or barriers that may be evidenced. |
709.93(a)(8) 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:
(8) Case consultation notes.
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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 case consultation notes entered every 90 days, per the facility's policy, in three of nine applicable records reviewed.
Client #1 was admitted on February 7, 2025 and was active at the time of the inspection. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
Client #2 was admitted on May 8, 2025 and was active at the time of the inspection. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
Client #6 was admitted on January 14, 2025 and was active at the time of the inspection. A case consultation note was not documented in the record within 90 days of the date of service, per the facility's policy.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff will receive a training on 10/9/2025 to review 709.93(a)(8) LICENSURE, Client records including the necessity to complete case consultations per facility policy.
The clinical supervisor will conduct monthly record audits of no less than 10 charts to ensure that case consultations are being completed in accordance with facility policy. Clinical supervisor will use a monthly report to identify patients that are coming due for a case consultation and will provide this information to the assigned clinician for that patient. |
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 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 two out of two applicable records reviewed.
Client #3 was admitted on September 13, 2021 and was discharged on April 10, 2025. There were 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 June 2, 2023 and was discharged on October 15, 2024. There were no 7 day, 30-day or 90-day follow-up contact information documented in the client record at the time of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff will receive a training on 10/9/2025 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. |