INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on October 9-10, 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-II, 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 April 2, 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 May 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.
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(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 in one of three applicable records.
Patient #1 was admitted on May 5, 2022, and discharged on September 18, 2025. The annual physical was due no later than May 5, 2025; however, it was completed on May 7, 2025.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to complete required documentation needed for a patient's annual physical evaluation in one reviewed chart.
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 & Physician Assistant.
Action steps and plan to address the completion of annual evaluations are (1) Supervisory Staff will review regulations around annual medical evaluations during Nov. medical team meeting. (2) Supervisory Staff will review monthly to double check annual medical evaluations compliance, report/review any issues, and review barriers to meeting this facility policy and procedure. (3) Medical staff will be trained on the new PowerTools that can be used to help ensure that all upcoming annual medical physicals are completed on time and to check for any that may have been missed prior to them being late. (4) Review of annual medical 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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709.93(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 five 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 #1 was admitted on May 5, 2022, and discharged on September 18, 2025. The 7-day follow-up was due no later than September 25, 2025; however, there was no follow-up in the record.
Client #2 was admitted on January 16, 2024, and discharged on February 7, 2025. The 30-day follow-up was due no later than March 7, 2025; however, it was completed on April 7, 2025.
Client #6 was admitted on December 19, 2024, and discharged on June 12, 2025. The 7-day follow-up was due no later than June 19, 2025; however, it was completed on June 20, 2025.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to provide a complete client record, which is to include follow-up information in three reviewed charts. Facility policy and procedure states that follow-up information will be obtained seven days, 30 days, and 60 days following discharge.
Clinical Supervisor & Director will review consent procedure Nov. staff meeting. While addressing this area, facility policies/procedure around discharge follow-ups will be reviewed.
Ongoing individual and group supervision will address progress in and completion of case consults to meet DDAP standards and regulations.
Action steps and plan to address the completion of discharge follow-ups are (1) External tracking system is implemented outside the current EMR to report and monitor completion of patient discharge follow-ups. Supervisory Staff will ensure that all clinical staff are appropriately trained on how to view and use this external tracking system. (2) Supervisory Staff will review facility policies/procedures around discharge follow-ups in clinical group supervision and staff meeting by the end of Nov. (3) Use of Tableau dashboards to help monitor when follow-ups are due, late, or missing. (4) Discharge follow-up requirements 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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