INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 8-9, 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-I, 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 facility failed to provide annual Project Director sign-off that approved updated and current facility policies and procedures.
The Project Director will review and ensure policies are updated/current and issue a signed attestation to that effect within the month of January every year.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to include the results of an annual evaluation of each patient ' s status completed by the patient ' s counselor and reviewed, dated and signed by the medical director in two of three applicable records.
The facility policy states the primary counselor will prepare an annual evaluation to be completed prior to the admission anniversary date, documenting the progress of each patient, which is reviewed/approved by the Program and Project Director and/or Program Director and filed in each patient' s record.
Patient #6 was admitted on December 31, 2024, and discharged on February 12, 2026. The annual evaluation was due no later than December 31, 2025; however, there was no evaluation documented in the record.
Patient #7 was admitted on December 27, 2023, and discharged on July 23, 2026. The annual evaluation was due no later than December 31, 2025; however, there was no evaluation documented in the record.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the September 16, 2021, September 27, 2022, September 26-27, 2023, August 13-14, 2024, and October 7-8, 2025, licensing inspections.
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Plan of Correction
The facility failed to complete required documentation needed for a patient's annual evaluation in two reviewed charts.
Supervisory Staff will review requirements for annual evaluations being completed in clinical group supervision and staff meetings in both October and November staff meetings. While addressing this area, it will be reviewed that all patients must have annual evaluations completed annually based on the date of patient admission.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director & Clinical Supervisor.
Action steps and plan to address the completion of annual evaluations are (1) Supervisory Staff will review regulations around annual evaluations and education/training on timely completion of annual evaluations will be provided in clinical group supervision and staff meeting in both October and November. (2) Clinical staff will be refreshed on PowerTools document tracking system for when annual evaluation updates are due for each patient, which is now color-coded, and place flags/holds when needed. (3) Supervisor staff will review PowerTools document tracking system throughout each month, and place flags/holds on out of date/missing annual evaluation updates and upcoming annual evaluation updates if clinical staff has not already done so. (4) Supervisory Staff will review monthly to double check annual evaluations compliance, report/review any issues, and review barriers to meeting this facility policy and procedure. (5) Review of annual documentation will be a part of any IAuditor chart review and will be reviewed/monitored with random chart audits completed by supervisory staff and compliance team.
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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 six applicable records.
Client #2 was admitted on January 7, 2026, and was still active at the time of inspection. A treatment plan was developed on January 21, 2026, and an update was due no later than March 21, 2026; however, it was not completed until April 21, 2026.
Client #4 was admitted on December 5, 2025, and discharged on May 28, 2026. A treatment plan was developed on December 17, 2025, and an update was due no later than February 17, 2026; however, it was not completed until February 25, 2026.
Client #5 was admitted on February 6, 2019, and was still active at the time of inspection. A treatment plan update was completed on January 22, 2026, and the next update was due no later than March 22, 2026; however, it was not completed until March 30, 2026.
Client #7 was admitted on December 27, 2023, and discharged on July 23, 2026. A treatment plan update was completed on October 20, 2025, and the next update was due no later than December 20, 2025; however, it was not completed until December 24, 2025.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the October 7-8, 2025, licensing inspection.
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Plan of Correction
The facility failed to complete all the required documentation for individual treatment and rehabilitation plan updates in four reviewed charts.
Supervisory Staff will review requirements for completion of comprehensive treatment plans in Oct./Nov. staff meetings. While addressing this area, it will be reviewed that all patients must have treatment plan updates completed within 60 days of the previous update. Ongoing individual and group supervision will address progress in and completion of treatment plan updates to meet DDAP standards and regulations.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director & Clinical Supervisor.
Action steps and plan to address the completion of treatment plan updates when required by regulation are (1) Supervisory Staff will review regulations around comprehensive treatment plan updates in clinical group supervision and staff meeting throughout the months of October and November. (2) Clinical staff will be refreshed on PowerTools document tracking system for when treatment plan updates are due for each patient, which is now color-coded, and place flags/holds when needed. (3) Supervisor staff will review PowerTools document tracking system throughout each month, and place flags/holds on out of date/missing treatment plan updates and upcoming treatment plan updates if clinical staff has not already done so. (4) Monthly individual supervision will address completion of treatment plan updates and barriers to meeting this regulation. (5) Education and training on timely completion of treatment plan updates will be part of group supervision and staff meetings. (6) Review of comprehensive treatment plans updates will be a part of any IAuditor chart review and will be reviewed/monitored with random chart audits completed by supervisory staff and compliance team.
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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 #3 was admitted on November 4, 2025, and discharged on May 5, 2026. The 7-day follow-up was due no later than May 12, 2026; however, it was not completed until September 7, 2026. The 30-day follow-up was due no later than June 5, 2026; however, it was not completed until September 7, 2026. The 60-day follow-up was due no later than July 5, 2026; however, it was not completed until September 7, 2026.
Client #4 was admitted on December 5, 2025, and discharged on May 28, 2026. The 7-day follow-up was due no later than June 4, 2026; however, it was not completed until September 7, 2026. The 30-day follow-up was due no later than June 28, 2026; however, it was not completed until September 7, 2026. The 60-day follow-up was due no later than July 28, 2026; however, it was not completed until September 7, 2026.
Client #6 was admitted on December 31, 2024, and discharged on February 12, 2026. There were no 7, 30, or 60-day follow-ups documented.
Client #7 was admitted on December 27, 2023, and discharged on July 23, 2026. The 7-day follow-up was due no later than July 30, 2026; however, it was not completed until September 6, 2026. The 30-day follow-up was due no later than August 23, 2026; however, it was not completed until September 6, 2026. The 60-day follow-up was due no later than August 23, 2026; however, it was not completed until September 6, 2026.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to provide a complete client record, which is to include follow-up information in four reviewed charts. Facility policy and procedure states that follow-up information will be obtained 7-days, 30-days, and 60-days post discharge.
Clinical Supervisor & Director will review current follow-up policies and procedures in Oct./Nov. staff meetings. While addressing this area, facility policies/procedure around discharge follow-ups will be reviewed.
Clinical Supervisor will continue to conduct ongoing individual, and group supervision that will address progress in and completion of required discharge follow-ups to meet current PTC policies and procedures.
Action steps and plan to address the completion of discharge follow-ups are (1) External tracking system is implemented outside the current EMR to report and monitor completion of patient discharge follow-ups. Supervisory Staff will ensure that all clinical staff are appropriately trained on how to view and use this external tracking system. (2) Supervisory Staff will review facility policies/procedures around discharge follow-ups in clinical group supervision and staff meeting by the end of Nov. (3) Use of Tableau dashboards and Power Tools system which is now color coded to help monitor when follow-ups are due, late, or missing. (4) Discharge follow-up requirements will be a part of any IAuditor chart review and will be reviewed/monitored with random chart audits completed by supervisory staff and compliance team. (5) Propose to PTC Compliance and Quality that the follow-up policy is reviewed and adjusted to be less restrictive and more in line with DDAP regulations.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for annual evaluations was submitted and approved by the Department for the September 16, 2021, September 27, 2022, September 26-27, 2023, August 13-14, 2024, and October 7-8, 2025, licensing inspections. Annual clinical evaluations were again found to be a deficiency in the September 8-9, 2026, licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility director will ensure the plans of corrections are implemented by the corrective action date and supervisory team will assist in the monitoring process. Additional monitoring will occur using Tableau reports, PowerTools, and chart audits completed by the PTC Quality Compliance Team and if deficiencies are noted they will be reviewed within the month with all site leadership. If the plan of corrections appears to not be working as written, adjustments will be made to the current plans during the supervisory meeting. PTC Compliance team will review current Policies and propose changes that will bring the policies more in line with DDAP regulations. The Facility Director will report to the project director the findings each quarter during PTCs regional operations meeting. |