INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone and buprenorphine monitoring inspection conducted on August 26-27, 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-IV, LLC dba Summit 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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709.23 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
Summit Facility 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 upcoming 10/6/26 Staff Meeting and Clinical Supervisor reviewed in 9/23/26 clinical meeting.
The Project Director will review and ensure policies are updated and issue a signed attestation to that effect by January 15, 2027. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records and incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving a death.The facility was informed of the death of a client on August 12, 2026, and did not inform the Department until August 27, 2026.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Summit Director will review completion of incident reports in upcoming 10/6/26 Staff Meeting and Clinical Supervisor reviewed in 9/23/26 clinical meeting. It will be reviewed that unusual incident reports are to be filed with the Department (DDAP) within 3 business days following an unusual incident involving a death.
Ongoing individual discussions with Facility Director and Clinical Supervisor will address timely completion and submission of incident reports to DDAP. Ensuring POC is being followed will be the responsibility of the Facility Director.
Action steps and plan to address the deficiency (1) The Facility Director will ensure plan of correction are implemented by the corrective action date. (2) Summit Clinical Supervisor addressed correct filing of incident reports in the 9/23/26 Clinical Meeting, (3) Facility Director will address the same information in the 10/6/26 staff meeting, (4) Facility Director and Clinical Supervisor will consult with each other at the time of each incident the time frame of completion of the incident report and the submission of those reports to ensure timeliness. (5) Facility Director, and 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. |
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 three applicable records.Patient #7 was admitted on November 25, 2024, and discharged on April 7, 2026. The annual physical examination was due no later than November 25, 2025; however, it was not documented until November 26, 2025. This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the September 10-12, 2025, licensing inspection.
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Plan of Correction
Summit Clinical Supervisor reviewed process of timely completion of the annual physical examination (and signature completed) in 9/23/26 Clinical Meeting and Director will review in upcoming 10/6/26 staff meeting. It will be reviewed that an annual physical must be completed in total and signed in a timely manner/by the due date.
Ongoing individual discussions with Medical Director and/or provider will address timely completion in total and signing of the annual physical to meet DDAP standards and regulations. Ensuring POC is being followed will be the responsibility of the Facility Director and Medical Director and/or provider.
Action steps and plan to address the deficiency (1) The Facility Director will ensure plan of correction are implemented by the corrective action date and the Medical Director will assist in monitoring the process (2) Summit Clinical Supervisor addressed that a narcotic treatment program provider must complete the annual physical examination in total (and sign) in a timely manner in the 9/23/26 Clinical Meeting, (3) Facility Director will address the same information in the 10/6/26 staff meeting, (4) Lead Counselor will complete chart audits randomly and ensure the Medical Director and/or provider has completed and signed the annual physical examination by the due date (5) Facility Director will review the above-mentioned patient charts with the Medical Director for purposes of quality review (6) Facility Director will address Medical Director and Physician Assistant with any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process. |
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 three 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 #5 was admitted on March 28, 2023, and discharged on May 15, 2026. The annual evaluation was due no later than March 28, 2026; however, it was not documented until April 8, 2026.Patient #6 was admitted on January 18, 2024, and discharged on February 24, 2026. The annual evaluation was due no later than January 18, 2026; however, there was no annual evaluation documented in the record.Patient #7 was admitted on November 25, 2024, and discharged on April 7, 2026. The annual evaluation was due no later than November 25, 2025; however, there was no annual evaluation documented in the record.This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the September 10-12, 2025, licensing inspection.
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Plan of Correction
Summit Clinical Supervisor reviewed completing the annual clinical evaluation in 9/23/26 Clinical Meeting and Director will review in upcoming 10/6/26 staff meeting. It will be reviewed that patients must have an annual clinical evaluation completed and signed by the counselor, clinical supervisor and Medical Director by the annual date of intake.
Ongoing individual and group supervision will address progress in completion of the annual clinical evaluation. Individual and group supervisions as well as ensuring POC is being followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the deficiency (1) The Facility Director will ensure plan of correction are implemented by the corrective action date and the clinical supervisor will assist in monitoring the process (2) Summit Clinical Supervisor addressed completion of the annual clinical evaluation and having appropriate signatures in the 9/23/26 Clinical Meeting, (3) Facility Director will address the same information in the 10/6/26 staff meeting, (4) Monthly individual supervision will address completion the annual clinical evaluation and ensuring all signatures are timely (5) Individual patient charts will be reviewed during some individual supervision sessions, (6) Lead Counselor will review patient chart audits (no less than 3/quarter) and review findings with Clinical Supervisor and Facility Director to ensure annual clinical evaluations are completed with signatures of the counselor, Clinical Supervisor and Medical Director by the annual due date (7) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process. |
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 develop an individual treatment and rehabilitation plan with the client within 30 days of admission, per facility policy, in three of four applicable records reviewed. Client #1 was admitted on June 5, 2026, and was still active at the time of inspection. The individual treatment and rehabilitation plan was due no later than July 5, 2026; however, it was not documented until July 27, 2026.Client #2 was admitted on December 29, 2025, and was still active at the time of inspection. The individual treatment and rehabilitation plan was due no later than January 28, 2026; however, it was not documented until March 10, 2026.Client #3 was admitted on November 18, 2025, and discharged on May 11, 2026. The individual treatment and rehabilitation plan was due no later than December 18, 2025; however, it was not documented until February 9, 2026.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed development of an individual treatment and rehabilitation plan with the client within 30 days of admission in the 9/23/26 Clinical Meeting and Director will review in upcoming 10/6/26 staff meeting. It will be reviewed that patients must have an individual treatment and rehabilitation plan within 30 days of admission
Ongoing individual and group supervision will address progress in development of an individual treatment and rehabilitation plan within 30 days of admission. Individual and group supervisions as well as ensuring POC is being followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the deficiency (1) The Facility Director will ensure plan of correction are implemented by the corrective action date and the clinical supervisor will assist in monitoring the process (2) Summit Clinical Supervisor addressed development of an individual treatment and rehabilitation plan with the client within 30 days of admission in the 9/23/26 Clinical Meeting, (3) Facility Director will address the same information in the 10/6/26 staff meeting, (4) Monthly individual supervision will address the development of an individual treatment and rehabilitation plan with the client within 30 days of admission (5) Individual patient charts will be reviewed during some individual supervision sessions, (6) Lead Counselor will review patient chart audits (no less than 3/quarter) and review findings with Clinical Supervisor and Facility Director to ensure the development of an individual treatment and rehabilitation plan with the client within 30 days of admission is done. (7) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process. |
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 60 days in four of six applicable records.Client #2 was admitted on December 29, 2025, and was still active at the time of inspection. A treatment plan was completed on March 10, 2026, and an update was due no later than May 10, 2026; however, it was not completed until May 15, 2026. Client #4 was admitted on December 2, 2025, and discharged on June 25, 2026. A treatment plan was completed on December 29, 2025, and an update was due no later than March 1, 2026; however, it was not completed until March 11, 2026. Client #5 was admitted on March 28, 2023, and discharged on May 15, 2026. A treatment plan update was completed on September 19, 2025, and the next update was due no later than November 19, 2025; however, it was not completed until November 25, 2025. Client #7 was admitted on November 25, 2024, and discharged on April 7, 2026. A treatment plan update was completed on October 16, 2025, and the next update was due no later than December 16, 2025; however, it was not completed until January 14, 2026.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from the September 10-12, 2025, licensing inspection.
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Plan of Correction
Summit Clinical Supervisor reviewed documenting treatment plan updates every 60 days in the 9/23/26 Clinical Meeting and Director will review in upcoming 10/6/26 staff meeting.
Ongoing individual and group supervision will address documenting treatment plan updates every 60 days in Individual and group supervisions as well as ensuring POC is being followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the deficiency (1) The Facility Director will ensure plan of correction are implemented by the corrective action date and the clinical supervisor will assist in monitoring the process (2) Summit Clinical Supervisor addressed documenting treatment plan updates every 60 days in the 9/23/26 Clinical Meeting, (3) Facility Director will address the same information in the 10/6/26 staff meeting, (4) Monthly individual supervision will address documenting treatment plan updates every 60 days (5) Individual patient charts will be reviewed during some individual supervision sessions, (6) Lead Counselor will review patient chart audits (no less than 3/quarter) and review findings with Clinical Supervisor and Facility Director to ensure documenting treatment plan updates every 60 days is done. (7) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process. |
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 the clients received counseling services according to their individual treatment plan in three of seven records.Client #2 was admitted on December 29, 2025, and was still active at the time of inspection. The treatment plans dated March 10, 2026, and May 15, 2026, indicated one individual counseling session per month. There was no individual counseling session documented for the months of April 2026 or July 2026.Client #4 was admitted on December 2, 2025, and discharged on June 25, 2026. The treatment plan dated March 11, 2026, indicated one individual counseling session per month. There was no individual counseling session documented for the months of February 2026 or March 2026.Client #7 was admitted on November 25, 2024, and discharged on April 7, 2026. The treatment plans dated October 16, 2025, and January 14, 2026, indicated one individual counseling session per month. There was no individual counseling session documented for the months of December 2025, January 2026, or March 2026.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from the September 10-12, 2025, licensing inspection.
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Plan of Correction
Summit Clinical Supervisor reviewed counseling services are provided according to the individual treatment and rehabilitation plan in the 9/23/26 Clinical Meeting and Director will review in upcoming 10/6/26 staff meeting.
Ongoing individual and group supervision will address counseling services are provided according to the individual treatment and rehabilitation plan in Individual and group supervisions as well as ensuring POC is being followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the deficiency (1) The Facility Director will ensure plan of correction are implemented by the corrective action date and the clinical supervisor will assist in monitoring the process (2) Summit Clinical Supervisor addressed counseling services are provided according to the individual treatment and rehabilitation plan in the 9/23/26 Clinical Meeting, (3) Facility Director will address the same information in the 10/6/26 staff meeting, (4) Monthly individual supervision will address counseling services are provided according to the individual treatment and rehabilitation plan (5) Individual patient charts will be reviewed during some individual supervision sessions, (6) Lead Counselor will review patient chart audits (no less than 3/quarter) and review findings with Clinical Supervisor and Facility Director to ensure counseling services are provided according to the individual treatment and rehabilitation plan . (7) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process. |
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 have a complete client record on an individual that included information relative to the client's involvement with the project, including follow-up information, at a minimum of 7-days, 30-days and 60-days post discharge, per facility policy, in four of five applicable records.Client #4 was admitted on December 2, 2025, and discharged on June 25, 2026. There was no documentation of a 30- or 60-day follow-up in the client record. Client #5 was admitted on March 28, 2023, and discharged on May 15, 2026. The 7-day follow-up was due no later than May 22, 2026; however, it was not completed until June 2, 2026. The 30-day follow-up was due June 15, 2026; however, it was not completed until July 2, 2026.Client #6 was admitted on January 18, 2024, and discharged on February 24, 2026. The 30-day follow-up was due no later than March 26, 2026; however, it was not completed until April 9, 2026. The 60-day follow-up was due April 26, 2026; however, it was not completed until May 12, 2026.Client #7 was admitted on November 25, 2024, and discharged on April 7, 2026. There was no documentation of the 30- or 60-day follow-up in the client record. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervisor reviewed follow-up information is complete, at a minimum of 7-days, 30-days and 60-days post discharge in the 9/23/26 Clinical Meeting and Director will review in upcoming 10/6/26 Staff meeting.
Ongoing individual and group supervision will address follow-up information being done, at a minimum of 7-days, 30-days and 60-days post discharge in Individual and group supervisions as well as ensuring POC is being followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
Action steps and plan to address the deficiency (1) The Facility Director will ensure plan of correction are implemented by the corrective action date and the clinical supervisor will assist in monitoring the process (2) Summit Clinical Supervisor addressed follow-up information being done, at a minimum of 7-days, 30-days and 60-days post discharge in the 9/23/26 Clinical Meeting, (3) Facility Director will address the same information in the 10/6/26 staff meeting, (4) Monthly individual supervision will address follow-up information being done, at a minimum of 7-days, 30-days and 60-days post discharge (5) Individual patient charts will be reviewed during some individual supervision sessions, (6) Lead Counselor will review patient chart audits (no less than 3/quarter) and review findings with Clinical Supervisor and Facility Director to ensure follow-up information is being done, at a minimum of 7-days, 30-days and 60-days post discharge . (7) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process. |