INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 20-22, 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-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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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 thirteen of eighteen weeks.Physician service hours were reviewed from June 1, 2025-October 4, 2025. For the week of June 1, 2025, through June 7, 2025, the facility's census was 631 patients. The facility was required to provide 63.1 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of June 8, 2025, through June 14, 2025, the facility's census was 631 patients. The facility was required to provide 63.1 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of June 15, 2025, through June 21, 2025, the facility's census was 633 patients. The facility was required to provide 63.3 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of June 22, 2025, through June 28, 2025, the facility's census was 635 patients. The facility was required to provide 63.5 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of June 29, 2025, through July 5, 2025, the facility's census was 634 patients. The facility was required to provide 63.4 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of July 6, 2025, through July 12, 2025, the facility's census was 633 patients. The facility was required to provide 63.3 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of July 13, 2025, through July 19, 2025, the facility's census was 633 patients. The facility was required to provide 63.3 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of July 20, 2025, through July 26, 2025, the facility's census was 632 patients. The facility was required to provide 63.2 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of July 27, 2025, through August 2, 2025, the facility's census was 632 patients. The facility was required to provide 63.2 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of August 3, 2025, through August 9, 2025, the facility's census was 631 patients. The facility was required to provide 63.1 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of August 10, 2025, through August 16, 2025, the facility's census was 633 patients. The facility was required to provide 63.3 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of August 17, 2025, through August 23, 2025, the facility's census was 633 patients. The facility was required to provide 63.3 hours of onsite physician services; however, the physician hours totaled 27 hours.For the week of August 24, 2025, through August 30, 2025, the facility's census was 630 patients. The facility was required to provide 63 hours of onsite physician services; however, the physician hours totaled 27 hours.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Action Steps 1: The ED monitored the census weekly beginning on 10/27/25 and will utilize the the Regional Medical Director to supplement hours to ensure the regulation is being met.
Action Steps 2 : Effective immediately and ongoing weekly beginning 10/27/25, ED will contact Regional Medical Director in the absence of facility MD as needed.
Action Steps 3: The Regional Director will monitor the plan of correction is being followed and will discuss each Monday morning with the Executive Director. |
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 #1 was admitted on April 18, 2023, and was still active at the time of the inspection. The annual physical examination was due no later than April 18, 2025; however, it was completed on September 24, 2025.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Action Steps
1: Facility director met with medical staff on 10/24/25 to review requirements regarding annual physicals.
2: Facility Director reviewed the spreadsheet that is used to track all annual physicals to ensure that are completed within the timeframe of the requirement. Facility Director also reviewed the report that tracks in EHR all annual physical upcoming and completed physicals. These are both to be used in comparison as a safeguard to ensure that are annual physicals are completed in a timely manner.
3. Facility Director and Office Manager will assist the nurses in monitoring the spreadsheet daily to ensure annual physicals are completed timely.
4. The patients will be notified in a timely manner of their scheduled physical a month, a week, and a day prior to their scheduled date and time. |
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 #5 was admitted on June 20, 2023, and discharged on August 5, 2025. The annual clinical evaluation was due no later than June 20, 2025; however, it was completed on July 9, 2025.Patient #7 was admitted on March 14, 2023, and discharged on July 2, 2025. The annual clinical evaluation was due no later than March 14, 2025; however, it was completed on March 28, 2025.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and ED met on 10/27/25 and reviewed the services due report in the EHR with all Clinical Staff.
Clinical supervisor and ED will monitor weekly for compliance that all annual clinical evaluation documentation is completed in a timely manner as well as all services due.
A services due spreadsheet was shared with all clinical staff. This is used as a safeguard for timely annual clinical documentation to be completed by the required due date.
Supervisors will review and update daily. Clinical supervisors will also review services due in both individual and group supervision to ensure compliance. |
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 #2 was admitted to the outpatient level of care on October 9, 2024 and was still active at the time of the inspection. A treatment plan was developed on October 9, 2024, and an update was due no later than December 9, 2024; however, it was completed on January 21, 2025.Client #3 was admitted to the outpatient level of care on February 18, 2025, and was still active at the time of the inspection. A treatment plan update was completed on May 6, 2025, and the next update was due no later than July 6, 2025; however, it was completed on July 11, 2025. Client #5 was admitted to the outpatient level of care on June 20, 2023, and discharged on August 5, 2025. A treatment plan update was completed on May 15, 2025, and the next update was due no later than July 15, 2025; however, it was completed on August 5, 2025. Client #7 was admitted to the outpatient level of care on March 14, 2023, and discharged on July 2, 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 21, 2025. Another treatment plan update was completed on April 11, 2025, and the next update was due no later than June 11, 2025; however, it was completed on July 2, 2025.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and ED met on 10/27/25 and reviewed the services due including treatment plan updates report in the EHR with all Clinical Staff.
Clinical supervisor and ED will monitor weekly for compliance that all treatment plan updates are completed in a timely manner as well as all services due.
A services due spreadsheet was shared with all clinical staff. This is used as a safeguard for treatment plan updates to be completed by the required due date.
The clinical staff also reviewed each of their trackers they use to ensure that all treatment plan updates are being completed by the required due date.
Supervisors will review and update daily. Clinical supervisors will also review services due in both individual and group supervision to ensure compliance. |
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 four 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 to the outpatient level of care on April 1, 2025, and discharged on September 5, 2025. The 7-day follow-up was due no later than September 12, 2025; however, it was completed on September 17, 2025. The 30-day follow-up was due no later than October 5, 2025; however, it was completed on October 14, 2025.Client #5 was admitted to the outpatient level of care on June 20, 2023, and discharged on August 5, 2025. The 30-day follow-up was due no later than September 5, 2025; however, it was completed on September 10, 2025. The 60-day follow-up was due no later than October 5, 2025; however, it was completed on October 22, 2025.Client #6 was admitted to the outpatient level of care on December 26, 2024, and discharged on April 16, 2025. The 7-day follow-up was due no later than April 23, 2025, 2025; however, it was completed on April 24, 2025. The 30-day follow-up was due no later than May 16, 2025; however, it was completed on May 22, 2025. The 60-day follow-up was due no later than June 16, 2025; however, it was completed on July 1, 2025.Client #7 was admitted to the outpatient level of care on March 14, 2023, and discharged on July 2, 2025. The 30-day follow-up was due no later than August 2, 2025, and the 60-day was due no later than September 2, 2025; however, there was no 30- or 60-day follow-up in the record.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and ED on 10/27/25 reviewed the services due report in Methasoft with all Clinical Staff. Clinical supervisor and ED will monitor weekly for compliance with follow ups as well as all services due. A follow up spreadsheet that was shared with all clinical staff was also created as a safeguard for timely follow up completion. Supervisors will review and update daily. Clinical supervisors will also review services due in both individual and group supervision to ensure compliance. |