INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 29-October 1, 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-VI, LLC dba Greenfield Counseling, 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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven records. Client #1 was admitted on March 7, 2025, and was still active at the time of inspection. The record did not contain a release of information for the funder or the transferring facility. The facility confirmed billing had occurred and a fax was sent to the transferring facility on March 7, 2025. Client #2 was admitted on April 7, 2025, and was still active at the time of inspection. The record did not contain a release of information for the funder. The facility confirmed billing had occurred.Client #6 was admitted on March 21, 2025, and discharged on July 16, 2025. The record did not contain a release of information for the funder. The facility confirmed billing had occurred. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director and Lead Counselor reviewed the list of required ROIs with all staff on 10/9/25, as well as all documents needed for Transfer In/Out. All charts were audited for all necessary ROIs by 10/17/25. All charts requiring ROIs will be updated by 10/31/25.
Progress with be monitored and verified by the Executive Director with support from the Lead Counselor. Ongoing compliance will be monitored by the Lead Counselor when completing intake audits.
The billing department has been alerted to charts without ROIs that have had billing submitted by 10/17/25.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of medical staff coverage, the facility failed to provide narcotic treatment physician services for at least 1 hour per week onsite for every ten patients for two of seventeen weeks.Physician service hours were reviewed from May 18-September 13, 2025. For the week of June 29, 2025, through July 5, 2025, the facility's census was 235 patients. The facility was required to provide 23.5 hours of onsite physician services; however, the physician hours totaled 20 hours.For the week of July 27, 2025, through August 2, 2025, the facility's census was 237 patients. The facility was required to provide 23.7 hours of onsite physician services; however, the physician hours totaled 20 hours.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
We are now utilizing Telehealth, accessing physicians and extenders who work at other Pinnacle Treatment Centers facilities to cover for MD and extender absences/PTO. We now have access to coverage for all hours that the facility is in operation.
Executive Director, Lead Counselor, and Nurses have access to the Telehealth request/scheduling system. The named roles will work together to schedule coverage for MD/NP absences, with the Executive Director ultimately monitoring need, scheduling, and compliance via invoices/timesheets and company-created monitoring dashboards. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure each medication order for a schedule change was written and signed by the narcotic treatment physician in six of six applicable records.Patient #1 was admitted on March 7, 2025, and was still active at the time of inspection. Per the dosing history, take homes were given on March 7, 2025; however, there was no corresponding medication order documented.Patient #2 was admitted on April 7, 2025, and was still active at the time of inspection. Per the dosing history, take homes were given on April 7, 2025, May 15, 2025, and June 24, 2025; however, there were no corresponding medication orders documented.Patient #3 was admitted on January 3, 2024, and was still active at the time of the inspection. Per the dosing history, take homes were given on February 17, 2025, April 11, 2025, and May 16, 2025; there were no corresponding medication orders documented.Patient #4 was admitted on April 22, 2021, and discharged on August 25, 2025. Per the dosing history, take homes were given on May 12, 2025; however, there was no corresponding medication order documented.Patient #5 was admitted on December 7, 2016, and discharged on July 17, 2025. Per the dosing history, take homes were revoked on February 21, 2025; however, there was no corresponding medication order documented. Patient #6 was admitted on March 21, 2025, and discharged on July 16, 2025. Per the dosing history, take homes were given on March 21, 2025, and March 24, 2025; however, there were no corresponding medication orders documented.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director met with the clinic MD on 10/9/25 and reviewed policy around take homes and take home order documentation and that he must be entering an order, not just signing the Take Home 6 Point Evaluation and having nursing update the EHR. MD has been entering the orders effective 10/9/25 and this is being monitored by the nurses with reporting to the Executive Director. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient in one of one applicable record. Patient #5 was admitted on December 7, 2016, and discharged on July 17, 2025. A fax was sent to the receiving facility and did not include the psychosocial summary.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director and Lead Counselor reviewed transfer policy and required documentation with clinical staff on 10/9/25. The above listed staff members are monitoring compliance by confirming documents going forward. |
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 two applicable records. Patient #6 was admitted on March 21, 2025, and discharged on July 16, 2025.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director and Lead Counselor reviewed transfer policy and required documentation with clinical staff on 10/9/25. The above listed staff members are monitoring compliance by confirming documents going forward. |
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 three of four applicable records.Patient #4 was admitted on April 22, 2021, and discharged on August 25, 2025. The annual physical examination was due no later than April 22, 2025; however, it was completed on April 23, 2025.Patient #5 was admitted on December 7, 2016, and discharged on July 17, 2025. The annual physical examination was due no later than December 7, 2024; however, it was completed on February 5, 2025.Patient #7 was admitted on December 5, 2019, and discharged on April 27, 2025. The annual physical examination was due no later than December 15, 2024; however, there was no annual physical in the record. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 10/1/25 all annual physicals are being scheduled a month prior to their due date by the Lead Counselor with the support of the Receptionist with either the MD or CRNP and completed no later than their due date based on patient's most recent admission.
Executive Director will monitor via feedback from the Receptionist and Lead Counselor on scheduling compliance and via reports generated by the EHR as well as company created monitoring dashboards. |
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 clinical evaluation in two of four applicable records.Patient #3 was admitted on January 3, 2024, and was still active at the time of the inspection. The annual clinical evaluation was due no later than January 3, 2025; however, it was completed on January 14, 2025.Patient #7 was admitted on December 5, 2019, and discharged on April 27, 2025. The annual clinical evaluation was due no later than December 5, 2024; however, it was completed on December 6, 2024.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective March 6, 2025 all staff were retrained on Annual Clinical Renewal completion and scheduling. That patients do not need to be present as a way of addressing AWOL patients was renewed as practice. Patients with a high number of THBs are to be completed at patients' in-clinic presentation prior to due date. To facilitate timely completion staff are provided with lists of upcoming annuals a month prior to their due dates, as well as beginning of month reminders by the Executive Director and Lead Counselor. All current charts are up to date.
Executive Director will monitor compliance with follow-up checks in the EHR and by use of company created monitoring dashboards. |
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 seven records.Client #3 was admitted on January 3, 2024, and was still active at the time of the inspection. A treatment plan update was completed on November 27, 2024, and the next update was due no later than January 27, 2025; however, it was completed on January 28, 2025.Client #5 was admitted on December 7, 2016, and discharged on July 17, 2025. A treatment plan update was completed on January 6, 2025, and the next update was due no later than March 7, 2025; however, it was completed on March 10, 2025. Another treatment plan update was completed on May 9, 2025, and the next update was due no later than July 9, 2025; however, it was completed on July 10, 2025.Client #6 was admitted on March 21, 2025, and discharged on July 16, 2025. An initial treatment plan was developed on March 25, 2025, and an update was due no later than May 25, 2025; however, it was completed on June 5, 2025.Client #7 was admitted on December 15, 2019, and discharged on April 27, 2025. A treatment plan update was completed on December 13, 2024, and the next update was due no later than February 13, 2025; however, it was completed on February 14, 2025.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective May 1 2025 Counselors were retrained on treatment planning timelines and are provided with ongoing updates of treatment plan due dates by the Executive Director and Lead Counselor, starting two months prior to the due date, and then weekly. Treatment plans are being completed in advance of due dates, or if patient is absent updates are being completed and then reviewed/renewed when the patient is present. Counselors are covering treatment plan update appointments, or requesting assistance from the ED and/or Lead Counselor if they are unable to complete treatment plans. As of 10/1/25 all charts are up to date. The Executive Director with the support of the Lead Counselor are providing continual monitoring. |
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 three of four applicable records.The facility's policy and procedures state follow up contact is to be completed for all discharges at 7, 30, and 60 days.Client #5 was admitted on December 7, 2016, and discharged on July 17, 2025. The 7-day follow-up was due no later than July 24, 2025; however, it was completed on July 28, 2025.Client #6 was admitted on March 21, 2025, and discharged on July 16, 2025. The 7-day follow-up was due no later than July 23, 2025; however, it was completed on July 28, 2025.Client #7 was admitted on December 5, 2019, and discharged on April 27, 2025. The 7-day follow-up was due no later than May 4, 2025; however, it was completed on May 7, 2025.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Follow-up policies were reviewed with staff on 10/9/25. Effective that date the Executive Director and Lead Counselor will add manual reminders to counselor schedules. A list of all follow-ups due will be transmitted to staff via Teams weekly by the Lead Counselor.
Executive Director or Lead Counselor as designated will monitor compliance by checking the chart prior to end of day on identified due dates. |