INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 7-8, 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-I, 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 #5 was admitted on September 16, 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 #7 was admitted on March 19, 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
The facility failed to appropriately document informed and voluntary consent in two records that were reviewed.
Clinical Supervisor & Director will review consent procedure Nov. 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 Facility Director & Clinical Supervisor.
Clinical staff will gain updated MOC release of information during sessions over the next few months to ensure compliance of all active patients by end of Jan. 2026.
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) Supervisory Staff will address consents for funders in the Nov. staff meeting. (3) Monthly individual supervision will address completion of consents for funders. (4) Supervisory Staff 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) Facility Director will review intake funder consents with office manager to ensure funder consents are being completed during admission. (7) Supervisory Staff will address any issues with noncompliance 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 three of three applicable records.
Patient #1 was admitted on July 16, 2016, and discharged on October 3, 2025. The annual clinical evaluation was due no later than July 16, 2025; however, it was completed on July 30, 2025.
Patient #2 was admitted on October 13, 2023, and discharged on October 18, 2024. The annual clinical evaluation was due no later than October 13, 2025; however, there was no evaluation in the record.
Patient #3 was admitted on May 24, 2019, and discharged on September 5, 2025. The annual clinical evaluation was due no later than May 24, 2025; however, there was no evaluation in the record.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the September 16, 2021, September 27, 2022, September 26-27, 2023, and August 13-14, 2024, licensing inspections.
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Plan of Correction
The facility failed to complete required documentation needed for a patient's annual evaluation in three reviewed charts.
Supervisory Staff will review requirements for annual evaluations being completed in clinical group supervision and staff meeting by 12/12/25. While addressing this area, it will be reviewed that all patients must have annual evaluations completed annually based on the date of patient admission.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director & Clinical Supervisor.
Action steps and plan to address the completion of annual evaluations are (1) Supervisory Staff will review regulations around annual evaluations and education/training on timely completion of annual evaluations will be provided in clinical group supervision and staff meeting. (2) Supervisor staff will review and send to all clinical staff annual evaluations compliance pre EMR reports and Tableau weekly including out of date/missing annual evaluations and upcoming annual evaluations. (3) Supervisory Staff will review monthly to double check annual evaluations compliance, report/review any issues, and review barriers to meeting this facility policy and procedure. (4) Clinical staff will be trained on the new PowerTools that can be used to help track caseload admission dates needed to complete annual evaluations on time. (5) Review of annual documentation 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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709.92(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 #1 was admitted on July 16, 2016, and discharged on October 3, 2025. A treatment plan update was completed on October 23, 2024, and the next update was due no later than December 23, 2024; however, it was completed on January 2, 2025. Another treatment plan update was completed on June 18, 2025, and the next update was due no later than August 18, 2025; however, there were no further updates in the record.
Client #3 was admitted on May 24, 2019, and discharged on September 5, 2025. A treatment plan update was completed on May 21, 2025, and the next update was due no later than July 21, 2025; however, it was completed on August 13, 2025.
Client #4 was admitted on October 23, 2024, and discharged on April 2, 2025. A treatment plan update was completed on November 20, 2024, and the next update was due no later than January 20, 2025; however, it was completed on February 5, 2025.
Client #6 was admitted on May 13, 2025, and was still active at the time of inspection. A comprehensive treatment plan was developed on May 13, 2025, and an update was due no later than July 13, 2025; however, it was completed on July 16, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to complete all the required documentation for individual treatment and rehabilitation plan updates in four reviewed charts.
Supervisory Staff will review requirements for completion of comprehensive treatment plans throughout the months of November and December. While addressing this area, it will be reviewed that all patients must have treatment plan updates completed within 60 days of the previous update. Ongoing individual and group supervision will address progress in and completion of treatment plan updates to meet DDAP standards and regulations.
Ongoing individual and group supervision as well as ensuring POC is followed will be the responsibility of the Facility Director & Clinical Supervisor.
Action steps and plan to address the completion of treatment plan updates when required by regulation are (1) Supervisory Staff will review regulations around comprehensive treatment plan updates in clinical group supervision and staff meeting throughout the months of November and December. (2) Supervisor staff will review and send to all clinical staff treatment plan compliance pre EMR reports and Tableau weekly including out of date/missing treatment plan updates and upcoming treatment plan updates. (3) Clinical staff will be trained on the new PowerTools that can be used to help track when caseload treatment plan updates are due for each patient. (4) Monthly individual supervision will address completion of treatment plan updates and barriers to meeting this regulation. (5) Individual patient charts will be reviewed during specific individual supervision sessions and completion of treatment plan updates will be part of that review. (6) Education and training on timely completion of treatment plan updates will be part of group supervision and staff meetings. (7) Review of comprehensive treatment plans updates 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. |
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 16, 2021, September 27, 2022, September 26-27, 2023, and August 13-14, 2024, licensing inspections. Annual clinical evaluations were again found to be a deficiency in the October 7-8, 2025, licensing inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility director will ensure the plans of corrections are implemented by the corrective action date and supervisory team will assist in the monitoring process. Additional monitoring will occur using Tableau reports, PowerTools, and chart audits completed by the PTC Quality Compliance Team and if deficiencies are noted they will be reviewed within the month during monthly compliance meetings. Supervisory Staff, Quality Compliance Team, and Facility Director will monitor continued implementation of the plans through quarterly meetings and review noticed issues occur during staff/supervision meetings. If the plan of corrections appears to not be working as written, adjustments will be made to the current plans during the supervisory meeting. The Facility Director will report to the project director the findings each quarter during PTCs regional operations meeting. |