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 9 & 10, 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-VIL dba Hanover 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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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.
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Observations
Based on a review of records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information contained in the client record in eight out of eleven records reviewed.Client #1 was admitted on February 5, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #3 was admitted on October 9, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for services. Client #4 was admitted on April 30, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for services. Client #5 was admitted on June 21, 2023 and discharged on March 31, 2025. There was no documentation that the facility obtained an informed and voluntary consent for a legal entity; however, there was documentation that the facility sent a letter to a legal entity on February 11, 2025. Client #8 was admitted on September 5, 2017 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for a legal entity; however, there was documentation that the facility sent a letter to a legal entity on July 10, 2025. Client #9 was admitted on May 7, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for services. Client #10 was admitted on February 19, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for services. Client #11 was admitted on December 11, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ED held staff meeting on 9/17/25, to review DDAP citations with staff. It was determined that in order to ensure all patients' have an ROI for their funding source, the front desk receptionist will enter an ROI for the patients' funding source when the patient presents their insurance card upon admission (as well as anytime they present a new card). This will also be added to the admissions check list, as a secondary measure, so that staff completing paperwork can also ensure this has been completed. Also, the ED must sign off on all out-going documentation to ensure that proper documentation has been completed. ED and CS will continue to complete both intake and monthly chart audits to ensure ROIs have been obtained as required. |
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 an annual physical examination within the regulatory timeframe in one out of four applicable records reviewed.Patient #8 was admitted on September 5, 2017 and was still active at the time of the inspection. The annual physical examination was due no later than September 5, 2025; however, there was no documentation that one was completed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
ED held staff meeting on 9/17/25, to review DDAP citations with staff. All staff training was provided on managing caseloads and caseload documentation to ensure that annual physicals are scheduled and completed on or prior to the due date. ED provided training to front desk staff to ensure they are aware of the procedures when assisting to schedule annual physicals, so they are completed on time or prior to the due date. ED and CS will conduct at least 1 monthly chart audit to review patient charts for annual physical documentation and completion on or prior to the due date. The monthly audits will assist in assuring that the corrective action and training is being implemented and annual physicals and documentation of such are being completed on or prior to the due date. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in two out of six applicable records reviewed. The facility ' s policy and procedures manual states that a comprehensive treatment plan is due within fourteen days of admission. Client #1 was admitted on February 5, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 19, 2025; however, it was not completed until February 24, 2025. Client #9 was admitted on May 7, 2025 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 21, 2025; however, it was not completed until May 23, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ED held staff meeting on 9/17/25, to review DDAP citations with staff. It was determined that after completing BPS Part 2, staff will schedule the patient within 1 week to complete their initial comprehensive treatment plan, to ensure that it is completed and signed within 14 days from admission. In addition, CS will conduct intake audits and follow up on these intakes during weekly supervision with the Counselor, to ensure the Comprehensive Treatment Plan has been completed, or that the patient is scheduled to complete. At least 1 monthly chart audit will also identify if the Corrective Action is being implemented. |
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 facility failed to ensure that the clients received counseling services according to their individual treatment plan in four out of eleven applicable records reviewed.Client #1 was admitted on February 5, 2025 and was still active at the time of the inspection. The treatment plan dated February 24, 2025, indicated four individual counseling sessions a month, There was documentation that the client only received three individual sessions in the month of March 2025. The treatment plan dated May 5 and July 14, 2025, indicated two individual sessions a month. There was documentation that the client only received one individual session in May and July 2025. Client #3 was admitted on October 9, 2024 and was still active at the time of the inspection. The treatment plan dated October 16, 2024, indicated four individual sessions a month. There was documentation that the client only received three individual sessions in the month of November 2025. Client #9 was admitted on May 7, 2025 and was still active at the time of the inspection. The treatment plan dated May 23, 2025, indicated four individual sessions a month. There was documentation that the client only received two sessions in the month of June 2025. Client #11 was admitted on December 11, 2024 and was still active at the time of the inspection. The treatment plan dated March 12 and May 9, 2025, indicated two counseling sessions a month. There was documentation that the client only received one individual session the month of May 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ED held staff meeting on 9/17/25, to review DDAP citations with staff. Training was provided on case management and it was determined that the Counselor will schedule all patients for their next session at the end of their completed appointment. If a patient is to be seen more than once, the Counselor will place the patient on recurring appointments. When a patient does not show the counselor will call the patient and document all attempts to re-engage; reschedules will also be documented. If it is determined the patient's prescribed counseling services can be reduced, the counselor will update the rehabilitation plan to ensure the patient is receiving counseling services per the rehabilitation plan. CS will monitor monthly requirements report and scheduled scheduling appointments during weekly SV, to ensure the POC is being following. |