INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 28-30, 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-V-III, 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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709.28 (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 two of seven records. Client #1 was admitted on February 13, 2025, and was still active at the time of inspection. There was no release of information for the funder in the record. The facility confirmed billing had occurred. Client #3 was admitted on March 25, 2025, and was still active at the time of inspection. There was no release of information for the funder in the record. 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
Charleroi Treatment Services Clinical Supervisor and Executive Director will review consent procedure for the upcoming 12/4/25 Clinical Meeting/Staff Meeting. It will be reviewed that patients must have consents completed with all valid funders.
Ongoing individual and group supervision will address progress in completion of consents for funders to meet DDAP standards and regulations. Also, Clinical Supervisor will complete a chart review on each intake to ensure consents for funders are completed. These chart reviews along with the individual and group supervisions as well as ensuring POC is being followed will be the responsibility of the Executive Director and Clinical Supervisor.Action steps and plan to address the deficiency (1) The Executive Director will ensure plan of correction are implemented by the corrective action date and the clinical supervisor will assist in monitoring the process (2) Clinical Supervisor will address consents for funders in the 12/4/25 Staff and Clinical meeting (3) Monthly individual supervision will address completion of consents for funders (4) Clinical Supervisor will complete the intake chart audits on 100% of intakes to ensure consents are being completed (5) Individual patient charts will be reviewed during some individual supervision sessions, (6) Executive Director will review intake and active chart audits (no less than 3/quarter) and review findings with Clinical Supervisor to ensure funder consents are being completed and Clinical Supervisor will re-address with staff monthly if needed (7) Executive 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 (8) Executive Director will ensure all current and future clients will be compliant in having releases of information on funders. |
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 record. Patient #6 was admitted on July 7, 2020, and discharged on September 25, 2025. A fax was sent to the receiving facility and did not include a psychosocial summary.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Charleroi Treatment Services Clinical Supervisor will review process of sending correct patient information to a facility they are transferring to in the upcoming 12/4/25 Clinical and all Staff Meeting. It will be reviewed that a narcotic treatment program must 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 written consent of the patient.Ongoing individual and group supervision will address progress in process of sending above outlined patient records to a facility a patient is transferring to meet DDAP standards and regulations. Individual and group supervision as well as ensuring POC is being followed will be the responsibility of the Executive Director and Clinical Supervisor.
Action steps and plan to address the deficiency (1) The Executive Director will ensure plans of correction are implemented by the corrective action date and the clinical supervisor will assist in monitoring the process (2) The Clinical Supervisor will address that a narcotic treatment program must 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 written consent of the patient in the 12/4/25 Clinical and all Staff Meeting, (3) Executive Director will address and enforce the same information in the same all staff meeting, (4) Monthly individual supervision will address sending the above information for patients that transfer to other facilities (5) Individual patient charts will be reviewed during some individual supervision sessions, (6) Executive Director will review each patient chart that is being discharged to ensure above information is being sent to facilities the patient may be transferring to (7) Executive Director and the 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.(8)Executive Director will also keep an excel spreadsheet listing all transferred in/out patient list for record. |
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 #6 was admitted on July 7, 2020, and discharged on September 25, 2025. The annual physical was due no later than July 7, 2025; however, it was completed on July 9, 2025.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Charleroi Treatment Services Clinical Supervisor will review process of timely completion of the annual physical examination (and signature completed) in upcoming 12/4/25 Clinical and all Staff meetings. It will be reviewed that an annual physical must be completed and signed in a timely manner for each patient to complete by their annual due date. Giving the opportunity for education and what tools are accessible to each party involved.
Ongoing individual discussions with Medical Director and/or extender will address timely completion and signing of the annual physical to meet DDAP standards and regulations. Ensuring POC is being followed will be the responsibility of the Executive Director, and Medical Director and/or Extender.Action steps and plan to address the deficiency (1) The Executive Director will ensure plan of correction are implemented by the corrective action date and both the Medical Director and Extender will assist in monitoring the process (2) Clinical Supervisor will address that a narcotic treatment program provider must complete an annual physical examination (and sign) in a timely manner in the 12/4/25 Clinical Meeting, along with Director will address the same information in the 12/4/25 staff meeting, (3) Executive Director will review patient chart audits (no less than 3/quarter) and review findings with Medical Director and extenders to ensure annual physical examinations are being completed in a timely manner (4) Extender Director will address Medical Director and Extender 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 clinical evaluation in two of three applicable records.Patient #6 was admitted on July 7, 2020, and discharged on September 25, 2025. The annual clinical evaluation was due no later than July 7, 2025; however, there was no evaluation in the record. Patient #7 was admitted on December 18, 2018, and discharged on April 16, 2025. The annual clinical evaluation was due no later than December 18, 2024; however, it was completed on January 5, 2025.These findings were reviewed with the facility staff during the licensing process.This is a repeat citation from the September 24-25, 2024, and November 1, 2023, licensing inspections.
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Plan of Correction
Charleroi Treatment Services Clinical Supervisor will review process of timely completion of the annual Clinical examination (and signature completed) in upcoming 12/4/25 Clinical and all Staff meetings. It will be reviewed that an annual clinical evaluation must be completed and signed in a timely manner for each patient to complete by their annual due date. Giving the opportunity for education and what tools are accessible to each party involved.
Ongoing individual discussions with Clinical Supervisor will address timely completion and signing of the annual evaluation to meet DDAP standards and regulations. Ensuring POC is being followed will be the responsibility of the Executive Director, and Clinical Supervisor.Action steps and plan to address the deficiency (1) The Executive Director will ensure plan of correction are implemented by the corrective action date with Clinical Supervisor will assist in monitoring the process (2) Clinical Supervisor will address that a narcotic treatment program provider must complete an annual clinical evaluation (and sign) in a timely manner in the 12/4/25 Clinical Meeting, along with Director will address the same information in the 12/4/25 staff meeting, (3) Executive Director will review patient chart audits (no less than 3/quarter) and review findings with Clinical Supervisor to ensure annual clinical evaluations are being completed in a timely manner (4) Executive Director will address Clinical Supervisor with 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 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 #4 was admitted on January 10, 2025, and discharged on September 24, 2025. The 7-day follow-up was due no later than October 1, 2025; however, it was completed on October 10, 2025.Client #6 was admitted on July 7, 2020, and discharged on September 25, 2025. The 7-day follow-up was due no later than October 2, 2025; however, it was completed on October 10, 2025.Client #7 was admitted on December 18, 2018, and discharged on April 16, 2025. The 7-day follow-up was due no later than April 23, 2025; however, it was completed on October 8, 2025. The 30-day follow-up was due no later than May 16, 2025; however, it was completed on October 8, 2025. The 60-day follow-up was due no later than June 16, 2025; however, it was completed on October 8, 2025.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Charleroi Treatment Services Clinical Supervisor will review process of timely completion of the discharge follow-up procedures in upcoming 12/4/25 Clinical and all Staff meetings. It will be reviewed that discharge follow-ups must be completed and signed in a timely manner for each 7 day follow up, 30 day follow up, and 60 day follow up. Giving the opportunity for education and what tools are accessible to each party involved.
Ongoing individual discussions with Clinical Supervisor will address timely completion of each follow up to meet DDAP standards and regulations. Ensuring POC is being followed will be the responsibility of the Executive Director, and Clinical Supervisor.Action steps and plan to address the deficiency (1) The Executive Director will ensure plan of corrections are implemented by the corrective action date with Clinical Supervisor will assist in monitoring the process (2) Clinical Supervisor will address that a narcotic treatment program provider must complete all follow ups in a timely manner in the 12/4/25 Clinical Meeting, along with Director will address the same information in the 12/4/25 staff meeting, (3) Executive Director will review patient chart audits and review findings with Clinical Supervisor to ensure all follow ups are being completed in a timely manner (4) Executive Director will address Clinical Supervisor with any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process. |
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 clinical evaluations was submitted and approved by the Department for the September 24-25, 2024, and November 1, 2023, licensing inspections. Annual clinical evaluations were again found to be a deficiency in the October 28-30, 2025, licensing inspection.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Charleroi Treatment Services Clinical Supervisor will review process of timely completion of the annual Clinical examination (and signature completed) in upcoming 12/4/25 Clinical and all Staff meetings. It will be reviewed that an annual clinical evaluation must be completed and signed in a timely manner for each patient to complete by their annual due date. Giving the opportunity for education and what tools are accessible to each party involved.
Ongoing individual discussions with Clinical Supervisor will address timely completion and signing of the annual evaluation to meet DDAP standards and regulations. Ensuring POC is being followed will be the responsibility of the Executive Director, and Clinical Supervisor.Action steps and plan to address the deficiency (1) The Executive Director will ensure plan of correction are implemented by the corrective action date with Clinical Supervisor will assist in monitoring the process (2) Clinical Supervisor will address that a narcotic treatment program provider must complete an annual clinical evaluation (and sign) in a timely manner in the 12/4/25 Clinical Meeting, along with Director will address the same information in the 12/4/25 staff meeting, At intake with new readmit patients, will place reminder flags to complete annual clinical evaluations. Weekly the Clinical Supervisor will print out due dates for Annual Clinical Evaluations and provide to the assigned counselor for completion. (3) Executive Director will review patient chart audits (no less than 3/quarter) and review findings with Clinical Supervisor to ensure annual clinical evaluations are being completed in a timely manner (4) Executive Director will address Clinical Supervisor with any issues with non-compliance in this area and discuss any additional training or focus that is required to improve the process.(5) Executive Director and Clinical Supervisor will meet Bi-Monthly to review compliance with all clinical documentation. |