INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 10-12, 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-IV, LLC dba Summit Treatment Services, 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 one of five applicable records. Client #4 was admitted on April 29, 2025, and was still active at the time of inspection. There was no release of information for the funder in client #4 ' s record. The facility confirmed billing had occurred. This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the August 27-28, 2024, licensing inspection.
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Plan of Correction
Summit Clinical Supervior will review consent procedure in upcoming 10/8/25 Clinical Meeting and Director will reciew in upcomning 10/14 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, Summit Lead Counselor will complete a chart review on each intake to ensure consents for funders are being 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 and Lead Counselor.
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) Summit Clinical Supervior will address consents for funders in the 10/8/25 Clinical Meeting, (3) Facility Director will address consents for funders in the 10/14/25 staff meeting, (4) Monthly individual supervision will address completion of consents for funders (5) Lead Counselor will complete the intake chart audits on 100% of intakes to ensure consents are being completed (6) Individual patient charts will be reviewed during some individual supervision sessions, (7) Facility 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 (8) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to imporve the process (9) Facility 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 #2 was admitted on November 25, 2024, and discharged on February 26, 2025. A fax was sent to the receiving facility and did not include admission date, medical and psychosocial summaries, or urinalysis reports.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervior will review process of sending correct patient information to a facility they are transferring to in upcoming 10/8/25 Clinical Meeting and Director will reciew in upcomning 10/14 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 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 in order to meet DDAP standards and regulations. Individual and group supervisions as well as ensuring POC is being followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
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) Summit Clinical Supervior 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 and shall contain written consent of the patient in the 10/8/25 Clinical Meeting, (3) Facility Director will address the same infdormation in the 10/14/25 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) Facility 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) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to imporve the process. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a review of patient records, the facility failed to include the results of an initial intake physical examination in three of four records.Patient #1 was admitted on November 7, 2024, and was still active at the time of the inspection. Patient #1 ' s record had an initial dose documented on November 7, 2024, followed by doses documented on November 8-11, 2024. The initial intake physical was signed on November 12, 2024. Patient #6 was admitted on July 2, 2025, and was still active at the time of the inspection. Patient #6 ' s record had an initial dose documented on July 2, 2025, followed by doses documented on July 3-6, 2025. Patient documented as AWOL with no dose on July 7, 2025. The initial intake physical was signed on July 7, 2025. Patient #7 was admitted on May 21, 2025, and was still active at the time of the inspection. Patient #7 ' s record had an initial dose documented on May 21, 2025, followed by doses documented on May 22-23, 2025. Take home doses documented for May 24-25, 2025. The initial intake physical was signed on May 25, 2025. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervior will review process of timely completion of the intake physical examination (and signature completed) in upcoming 10/8/25 Clinical Meeting and Director will reciew in upcomning 10/14 staff meeting. It will be reviewed that an intake physical must be completed and signed in a timely maner for each intake of a new patient completed.
Ongoing individual discussions with Medical Director and/or provider will address timely completion and signing of the intake physical to meet DDAP standards and regulations. Ensuring POC is being followed will be the responsibility of the Facility Director, and Medical Director and/or provider.
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 Medical Director will assist in monitoring the process (2) Summit Clinical Supervior will address that a narcotic treatment program provider must complete an intake physical examination (and sign) in a timely manner in the 10/8/25 Clinical Meeting, (3) Facility Director will address the same infdormation in the 10/14/25 staff meeting, (4) Lead Counselor will complete an intake chart audit on 100% of incoming intakes and ensure the Medical Director and/or provider has completed and signed the intake physical examination (5) Facility Director will review each patient chart that is being intaked with Medical Director to ensure completion of the intake examination (6) Facility Director will address Medical Director and Physician Assistant with any issues with non-compliance in this area and discuss any additional training or focus that is required to imporve the process. |
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 two applicable records.Patient #3 was admitted on July 8, 2024, and was still active at the time of the inspection. The initial physical examination was documented on July 8, 2024, and the annual physical examination was due no later than July 8, 2025; however, it was documented on July 31, 2025. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervior will review process of timely completion of the annual physical examination (and signature completed) in upcoming 10/8/25 Clinical Meeting and Director will reciew in upcomning 10/14 staff meeting. It will be reviewed that an annual physical must be completed and signed in a timely maner for each patient completed by their annual due date.
Ongoing individual discussions with Medical Director and/or provider 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 Facility Director, and Medical Director and/or provider.
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 both the Medical Director and Physician Assistant will assist in monitoring the process (2) Summit Clinical Supervior will address that a narcotic treatment program provider must complete an annual physical examination (and sign) in a timely manner in the 10/8/25 Clinical Meeting, (3) Facility Director will address the same infdormation in the 10/14/25 staff meeting, (4) Facility Director will review patient chart audits (no less than 3/quarter) and review findings with Medical Director and Physicial assistance to ensure annual physical examinations are being completed in a timely manner (6) Facility Director will address Medical Director and Physician Assistant with any issues with non-compliance in this area and discuss any additional training or focus that is required to imporve 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 one of two applicable records.Patient #3 was admitted on July 8, 2024, and was still active at the time of the inspection. The annual clinical evaluation was due no later than July 8, 2025; however, it was signed by the counselor and the clinical supervisor on August 1, 2025. The annual clinical evaluation was not reviewed, dated and signed by the medical director. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervior will review completing the annual clinical evaluation in upcoming 10/8/25 Clinical Meeting and Director will reciew in upcomning 10/14 staff meeting. It will be reviewed that patients must have an annual clinical evaluation completed and signed by the counselor, clinical supervisor and Medical Director by the annual date of intake.
Ongoing individual and group supervision will address progress in completion of the annual clinical evaluation. Individual and group supervisions as well as ensuring POC is being followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
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) Summit Clinical Supervior will address completion of the annual clinical evaluation and having appropriate signatures in the 10/8/25 Clinical Meeting, (3) Facility Director will address the same information in the 10/14/25 staff meeting, (4) Monthly individual supervision will address completion the annual clinical evaluation and ensuring all signatures are timely (5) Individual patient charts will be reviewed during some individual supervision sessions, (6) Facility Director will review patient chart audits (no less than 3/quarter) and review findings with Clinical Supervisor to ensure annual clinical evaluations are completed with signatures of the counselor, Clinical Supervisor and Medical Director by the annual due date (7) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to imporve the process. |
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 three of six applicable records.Client #1 was admitted on November 7, 2024, and was still active at the time of the inspection. A treatment plan update was completed on April 4, 2025, and the next update was due no later than June 4, 2025; however, it was completed on June 26, 2025. Client #3 was admitted on July 8, 2024, and was still active at the time of the inspection. A treatment plan update was completed on October 4, 2024, and the next update was due no later than December 4, 2025; however, it was completed on December 9, 2025. Another treatment plan update was completed on April 4, 2025, and the next update was due no later than June 4, 2025; however, it was completed on July 1, 2025Client #4 was admitted on April 29, 2025, and was still active at the time of the inspection. A treatment plan update was completed on June 3, 2025, and the next update was due no later than August 3, 2025; however, it was completed on August 12, 2025.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervior will review completing treatment plan updates in a timely manner in upcoming 10/8/25 Clinical Meeting and Director will reciew in upcomning 10/14 staff meeting. It will be reviewed that patients must have treatment plans updated and signed timely every 60 days.
Ongoing individual and group supervision will address progress in completion of treatment plan updates to meet DDAP standards and regulations. Individual and group supervisions as well as ensuring POC is being followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
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) Summit Clinical Supervior will address completion of treatment plan updates in the 10/8/25 Clinical Meeting, (3) Facility Director will address completion of treatment plan updates in the 10/14/25 staff meeting, (4) Monthly individual supervision will address completion of treatment plan updates (completion in a timely manner with all signatures) (5) Individual patient charts will be reviewed during some individual supervision sessions, (6) Facility Director will review patient chart audits chart audits (no less than 3/quarter) and review findings with Clinical Supervisor to ensure treatment plan updates are being completed and Clinical Supervisor will re-address with staff monthly if needed (7) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to imporve the process. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure the clients received counseling services according to their individual treatment plan in four of six applicable records.Client #1 was admitted on November 7, 2024, and was still active at the time of the inspection. Type and frequency on treatment plans indicate two individual counseling sessions per month. Client #1 ' s record had zero sessions documented in December 2024, one session documented in January 2025, zero sessions documented in February 2025, one session documented in March, April, and May 2025, and no further sessions documented after May 27, 2025.Client #3 was admitted on July 8, 2024, and was still active at the time of the inspection. Type and frequency on treatment plans indicate one individual counseling session per month. Client #3 ' s record had zero sessions documented in May, June, and July 2025.Client #4 was admitted on April 29. 2025, and was still active at the time of the inspection. Type and frequency on treatment plans indicate one individual counseling session per month. Client # ' s record had zero sessions documented in June 2025. Client #6 was admitted on July 2, 2025, and was still active at the time of the inspection. Type and frequency on treatment plans indicate two individual counseling sessions per month. Client #6 ' s record had one session documented in August 2025. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Summit Clinical Supervior will review completing counseling services according to the treatment plans in upcoming 10/8/25 Clinical Meeting and Director will reciew in upcomning 10/14 staff meeting. It will be reviewed that patients must have counseling services completed per what is indicated in their treatment plan updates.
Ongoing individual and group supervision will address progress in completion of counseling services according to treatment plans to meet DDAP standards and regulations. Individual and group supervisions as well as ensuring POC is being followed will be the responsibility of the Facility Director, Clinical Supervisor and Lead Counselor.
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) Summit Clinical Supervior will address completion of counseling services according to treatment plans in the 10/8/25 Clinical Meeting, (3) Facility Director will address completion of counseling services accoring to treatment plans in the 10/14/25 staff meeting, (4) Monthly individual supervision will address completion of counseling services according to treatment plans (completion in a timely manner with all signatures) (5) Individual patient charts will be reviewed during some individual supervision sessions, (6) Facility Director will review patient chart audits (no less than 3/quarter) and review findings with Clinical Supervisor to ensure counseling services are completed according to treatment plans (7) Clinical Supervisor will re-address with staff monthly through Methasoft Montly Requirements Report (8) Facility Director, Clinical Supervisor and Lead Counselor will address any issues with non-compliance in this area and discuss any additional training or focus that is required to imporve the process. |