INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 9-10, 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-II, 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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715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on a review of patient records, the facility failed to secure a personal history from the patient within the first week of admission in one of four applicable records.
Patient #1 was admitted on November 20, 2025, and discharged on July 29, 2026. The personal history was due no later than November 27, 2025; however, it was not documented until December 2, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to secure a personal history from a patient within the first week of admission in one reviewed chart.
Clinical Supervisor & Director will review intake procedure and personal history requirements in Oct./Nov. staff meetings.
Clinical Supervisor will continue to conduct ongoing individual, and group supervision that will address progress in and completion of required around patient admissions.
Action steps and plan to address the completion of discharge follow-ups are (1) Supervisory Staff will check each admission documentation to ensure required completion. (2) Supervisory Staff will review patient admission process including the requirement to collect personal patient history in clinical group supervision and staff meeting by the end of Nov. (3) Patient admission requirements including the requirement to collect personal patient history within the first week of admission 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 two 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 December 3, 2025, and discharged on April 2, 2026. The 30-day follow-up was due no later than May 2, 2026; however, it was not completed until August 24, 2026.
Client #7 was admitted on November 21, 2024, and discharged on April 2, 2026. The 30-day follow-up was due no later than May 2, 2026; however, it was not completed until August 24, 2026.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 9-10, 2025, licensing inspection.
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Plan of Correction
The facility failed to provide a complete client record, which is to include follow-up information in two 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 inline with DDAP regulations.
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