INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 26-27, 2026, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Beacon Point Recovery Center LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment.
Client #1 was admitted on August 27, 2025, and discharged on August 31, 2025. There was no documentation in the client record to verify they had been notified, in writing, of an involuntary termination.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
A form will be created in KIPU (EMR) for notice of involuntary termination. A tech or the resident's therapist will complete the involuntary termination notification form when a resident is involuntarily terminated.
All techs and clinical staff will be retrained on the process for involuntarily terminating a resident to prevent a violation of this regulation.
Involuntary terminations will be audited monthly, ~5 charts per month, to verify the documentation process is being followed. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to document that the client was provided with the opportunity to request reconsideration of a decision terminating treatment.
Client #1 was admitted on August 27, 2025, and discharged on August 31, 2025. There was no documentation in the client record to verify they had been given an opportunity to request reconsideration of the decision to terminate their treatment.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
All staff will be retrained on the requirement to offer a resident the opportunity to provide a resident with an opportunity to request reconsideration of an involuntary termination. A tech or the residents therapist will document in the resident's file the resident's request for reconsideration and the decision on whether to reconsider the resident's involuntary discharge.
An audit of involuntarily discharges will be performed monthly for 3 months to identify any deficiencies to adherence with this policy. The Compliance Director will perform the audit and work with the Director or Operations to address any deficiencies. |