INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on May 15, 2023 through May 17, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of personnel files, the facility failed to ensure that all counselors met the educational and/or experiential qualifications in one of six applicable personnel records reviewed. Employee #9 was hired as a counselor on December 19, 2022. The employee does possess a qualifying bachelor's degree; however, the record and employee resume documented 3 months of clinical experience in a health or human service agency prior to being hired.This is a repeat citation from the April 29, 2022 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point has reviewed the credential requirements with the employee identified. Beacon Point's HR representative and Director of Compliance will collaborate to monitor all onboarding of staff to ensure all regulations are met prior to a start date being issued. HR and Director of Compliance will maintain hard copy files of all staff moving forward and inconsistencies, deficiencies, and/or barrier trends will be discussed during quarterly QA Leadership meetings. |
704.8(a)(1) - (5) & (b) LICENSURE Qualification Level
704.8. Qualifications for the position of counselor assistant.
(1) A Master's Degree in a human service area.
(2) A Bachelor's Degree in a human service area.
(3) Licensure in this Commonwealth as a registered nurse.
(4) An Associate's Degree in a human service area.
(5) A high school diploma or General Education Development (GED) equivalent.
(b) A counselor assistant shall also complete the training requirements in 704.11 (relating to staff development program).
|
Observations
Based on a review of personnel records, the facility failed to ensure that all counselor assistants met the educational qualifications in one of six applicable personnel records reviewed.Employee #12 was hired as a counselor assistant on May 16, 2022. The personnel record did not include documentation of a degree or diploma at the time of inspection. Therefore, the DDAP representative was unable to verify the educational credentials of the employee.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance was able to obtain a copy of the referenced employee's degree after the completion of our on-site inspection.
Director of Compliance will collaborate with HR representative to ensure all documentation and credentialing is received and approved per facility policy prior to a start date being issued to candidate. Effective 6/1/23, all employees have a New Hire Checklist to ensure all documentation is accounted for, reviewed, and approved by both HR and Compliance. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of personnel records, the facility failed to provide counselor assistants, who have a bachelor's degree, high school diploma or GED equivalent, with the appropriate regulatory clinical supervision in four of four applicable personnel records reviewed.Employee #13 was hired as a counselor assistant on April 10, 2023. The employee has a bachelor's degree in a qualifying field and can counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. Close supervision is defined as formal documented case review and an additional hour of direct observation by a supervising counselor or clinical supervisor once a week. The employee did not receive an hour of direct observation once a week as of the date of inspection. Employee #14 was hired as a counselor assistant on October 10, 2022. The employee has a bachelor's degree in a qualifying field and can counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment. Close supervision is defined as formal documented case review and an additional hour of direct observation by a supervising counselor or clinical supervisor once a week. The employee only received direct observation on October 31, 2022.Employee #15 was hired as a counselor assistant on January 11, 2022. The employee has a high school and can counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Direct observation is defined as in-person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities. The employee only received direct observation on June 3, 2022.Employee #16 was hired as a counselor assistant on January 3, 2023. The employee has a high school and can counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Direct observation is defined as in-person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities. The employee only received direct observation on January 16, 2023.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has reviewed the submitted credentials of all employees identified in this citation and have reviewed the requirements of the cited regulation with the Clinical Director and Clinical Supervisor. Observation schedules have been established and notes will be added to Supervision forms to evidence both the type of observation completed and assessment/results of said observation. Each Counselor Assist will also have written assessments completed every (3) months during their first year of employment to document their strengths and areas of improvement. Clinical Director will submit a copy of all progress assessments completed to Director of Compliance and noted trends/deficiencies will be discussed with Leadership team during quarterly QA meetings. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
|
Observations
Based on a review of personnel records, the facility failed to document to the facility director, upon the completion of each calendar year, that they are continuing to work towards counselor status in four of four applicable personnel records reviewed.Employee #11 was hired as a counselor assistant on December 20, 2021. There was no documentation to the facility director that they were working toward counselor status by the end of the 2022 calendar year as of the date of inspection.Employee #12 was hired as a counselor assistant on May 16, 2022. There was no documentation to the facility director that they were working toward counselor status by the end of the 2022 calendar year as of the date of inspection.Employee #14 was hired as a counselor assistant on October 10, 2022. There was no documentation to the facility director that they were working toward counselor status by the end of the 2022 calendar year as of the date of inspection.Employee #15 was hired as a counselor assistant on January 11, 2022. There was no documentation to the facility director that they were working toward counselor status by the end of the 2022 calendar year as of the date of inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has met with both Clinical Director and all staffed Counselor Assistants to discuss having the intention letter drafted and submitted to the Executive Director and/or Facility Director (whichever is staffed) for acknowledgement no later than 6/30/23. Director of Compliance has also added a line item to end of year agenda (Q4 QA Meeting) and on-boarding employee checklists to ensure these letters are submitted annually. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records, the facility failed to provide documentation of an individual training plan that is to be developed with input from both the employee and the supervisor in four of sixteen personnel records reviewed. Employee #1 was hired as the project director on January 1, 2023. The individual training plan, dated November 25, 2022, was not signed by the supervisor and there was not any other documentation in the record indicating the plan had input from the supervisor; therefore, the DDAP representative was unable to determine if the plan was developed with the input of the supervisor.Employee #2 was hired as a clinical supervisor on September 28, 2019. There was no current individual training plan documented in the record at the time of inspection.Employee #7 was hired as a counselor on April 17, 2023. There was no current individual training plan documented in the record at the time of inspection.Employee #13 was hired as a counselor assistant on April 10, 2023. There was no current individual training plan documented in the record at the time of inspection.This is a repeat citation from the May 25, 2021 and April 29, 2022 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has distributed Training Plans to all active employees. The employees have been asked to give an assessment for the year 2022 as well as to list any trainings they are interested in completing during the active calendar year (2023).
All active employees, except those otherwise delineated in the regulations, have been asked to complete (12) hours of applicable training yearly. All Training Plans are signed by the employee as well as their direct supervisor and kept on file with the Compliance department. All completed forms are to be on file no later than June 30, 2023. Director of Compliance will conduct quarterly audits of personnel files for all active and new employees, providing an updated status of outstanding Training Plan completions during quarterly QA meetings with Leadership.
Training Plan completion has been added to the on-boarding checklist each new employee completes during their first day of employment at BPR to ensure there is no lapse of planning moving forward.
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on the review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the regulatory timeframes in three of eight applicable personnel records reviewed. Employee #11 was hired as a counselor assistant on December 20, 2021 and was due to receive the HIV/AIDS training and the TB/STD training no later than December 20, 2022; however, there was no documentation of completed trainings at the time of inspection.Employee #12 was hired as a counselor assistant on May 16, 2022 and was due to receive the HIV/AIDS training and the TB/STD training no later than May 16, 2023; however, there was no documentation of completed trainings at the time of inspection.Employee #15 was hired as a counselor assistant on January 11, 2022 and was due to receive the HIV/AIDS training and the TB/STD training no later than January 11, 2023; however, there was no documentation of the completion of TB/STD training at the time of inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has collaborated with the facility's Lead Nurse to have this training added to the on-boarding checklist of all new employees moving forward. The employees identified in this citation have been scheduled to attend the needed trainings prior to 6/30/23. Training certificates will be maintained by the Director of Compliance and Clinical Director to ensure all timelines outlined in the regulations are routinely satisfied moving forward. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors during the facility's January 2022 through December 2022 training year in one of one applicable personnel record reviewed.Employee #10 was hired as a counselor on December 25, 2021. The personnel record documented 10 hours of annual training during the review period. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has reviewed the applicable regulations with the Clinical Director and a Training Plan has been completed with the identified employee which details how he plans to obtain the required number of hours prior to the end of this calendar year (2023). Provisions have been put into place to avoid this being an issue moving forward which includes Director of Compliance communicating with Clinical team on a monthly basis noting how many hours have been completed and how many hours are still needed. CEU completion/progress will also be discussed with Leadership team during quarterly QA meetings to ensure staff are continuously making progress towards required totals and/or barriers are discussed to implement provisions as needed. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
|
Observations
Based on a review of personnel records, the facility failed to ensure each counselor assistant shall complete at least 40 clock hours of training the during the first year of employment in three of three applicable personnel records reviewed. Employee #11 was hired as a counselor assistant on December 20, 2021. The employee record documented 13 clock hours of training during the first year of employment. Employee #12 was hired as a counselor assistant on May 16, 2022. The employee record documented 5 clock hours of training during the first year of employment. Employee #15 was hired as a counselor assistant on January 11, 2022. The employee record documented 22 clock hours of training during the first year of employment. These finding were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has reviewed the applicable regulations with the Clinical Director and a Training Plan has been completed with each of the identified employees which details how they plan to obtain the required number of hours prior to the end of this calendar year (2023). Provisions have been put into place to avoid this being a concern moving forward which includes Director of Compliance communicating with Clinical team on a monthly basis noting how many hours have been completed and how many hours are still needed for each member of the department. CEU completion/progress will also be discussed with Leadership team during quarterly QA meetings to ensure staff are continuously making progress towards required totals and/or barriers are discussed to implement provisions as needed. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
|
Observations
Based on a physical plant inspection, conducted on May 17, 2023 between 10:00AM and 11:00AM, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. Electrical outlets in the bathrooms of rooms 405, 407, 504, 508, 512 and 713 were burnt, posing an electrical safety hazard.The bathrooms in client bedrooms 402, 410, and 412 had dirt/grime and/or glue at the entrance of the shower stalls. This is a repeat citation from the April 29, 2022 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point acknowledges this as a repeat citation, however, for the purposes of clarification would like to note the outlets identified during the on-site 2023 licensing inspection were located in different areas of the client's rooms than those outlets identified during the on-site 2022 licensing inspection. The electrical outlets identified during the on-site 2023 licensing inspection (405, 407, 504, 508, 512, and 713) have been capped by our Property Manager (completed 5/26/23). Beacon Point's Operations Department will continue to conduct weekly room inspections of all client rooms moving forward to ensure all items required are present, operable, clean, and safe. It was confirmed on 5/17/2023 all identified outlets were still in safe working condition.
The adhesive identified on the floor of the showers located in rooms 402, 410, and 412 has been scraped by the Director of Operations to the best of our ability without permanently damaging the shower floor itself. Beacon Point's Operations Department will continue to conduct weekly room inspections of all client rooms moving forward to ensure all items required are present, operable, clean, and safe.
|
705.7 (b) (4) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
|
Observations
Based on a physical plant inspection, conducted on May 17, 2023 between 10:00AM and 11:00AM, the facility failed to ensure storage areas for food were free of food particles, dust or dirt.The watercooler, located in the 2nd floor conference room adjacent to the laundry room, had what appeared to be mold or mildew inside the watercooler bottle.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point received confirmation from our vendor noting the identified water cooler in this citation did have consumable water in it despite the algae being present (5/19/2023).
Beacon Point's Director of Operations removed the identified water cooler from the 2nd floor (completed 5/17/23).
Beacon Point's Operations Department will continue to conduct bi-weekly physical plant inspections to ensure all items present are operable, clean, and safe.
|
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in two of two applicable client records reviewed.The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.Client # 13 was admitted to the inpatient non-hospital activity on September 3, 2022 and was discharged against medical advice on September 26, 2022. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.Client # 14 was admitted to the inpatient non-hospital activity on July 1, 2022 and was discharged against medical advice on July 30, 2022. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has reviewed the applicable regulation with all department heads to ensure staff are reminded to contact EC for each abnormal discharge, when a valid consent is present and to include this information in the progress notes entered in the EMR.
Beacon Point's compliance department will continue to conduct bi-weekly audits of discharged client charts to ensure documentation is present of EC being contacted in all cases where there is a valid consent present.
|
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on the review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, in seven of eight applicable personnel records reviewed. Employee # 1 was hired as the project director on January 1, 2023. The annual written performance evaluation was completed on November 25, 2022; however, the evaluation was not reviewed and signed by the employee at the time of the inspection. Employee # 3 was hired as a clinical supervisor on February 28, 2023. The annual written performance evaluation was completed on October 4, 2022; however, the evaluation was not reviewed and signed by the employee at the time of the inspection. Employee #4 was hired as a counselor on July 13, 2022. The annual written performance evaluation was completed on April 1, 2023; however, the evaluation was not reviewed and signed by the employee at the time of the inspection. Employee #8 was hired as a counselor on March 14, 2022. The annual written performance evaluation was completed on June 23, 2022; however, the evaluation was not reviewed and signed by the employee at the time of the inspection. Employee #10 was hired as a counselor on January 25, 2021. The annual written performance evaluation was completed on February 21, 2023; however, the evaluation was not reviewed and signed by the employee at the time of the inspection. Employee #11 was hired as a counselor assistant on December 20, 2021. The annual written performance evaluation was completed on February 13, 2023; however, the evaluation was not reviewed and signed by the employee at the time of the inspection. Employee #15 was hired as a counselor assistant on January 11, 2022. The annual written performance evaluation was completed on February 21, 2023; however, the evaluation was not reviewed and signed by the employee at the time of the inspectionThis is a repeat citation from the May 25, 2021 and April 29, 2022 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has reformatted the facility's Employee Performance Evaluation form and distributed it to all department leads for use moving forward (Completed 5/19/2023). Form created requires both the employee signature as well as the supervisor's signature prior to being submitted to HR for filing. Hard copies of all completed performance evaluations will also be maintained by Director of Compliance to ensure implemented provision is effective and easy to access when needed. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of fourteen client records reviewed.Client #7 was admitted to inpatient non-hospital detoxification activity March 8, 2023 and was discharged on March 15, 2023. A release of information form to an outside individual was signed and dated by the client on March 8, 2023; however, the release form listed only the first name of the individual and not the full name of the person. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has followed up with our Admissions Coordinator to discuss what provisions should be put in place at times when our EMR is down and/or unable to accept signatures. It has been confirmed this chart had hard copy consents signed due to an internet outage, however, as noted failed to have all elements present to make the consents valid.
Admissions department has been re-educated on the importance of signed valid consents (completed 5/22/2023) and any deviation from the established protocol needs to be approved by the Director of Compliance prior to completion of admission process.
Compliance officer will continue to conduct routine audits of all client charts to ensure this not an identified issue moving forward.
|
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of fourteen client records reviewed. Client # 13 was admitted to the inpatient non-hospital activity on September 3, 2022 and was discharged on September 26, 2022. The release of information form to the emergency contact was signed by the client; however, the form did not include the date of the dated signature of the client. Additionally, the release of information form to the funding source was signed by the witness on September 29, 2022; however, the form did not include the dated signature of the client. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Beacon Point has updated our EMR "Authorization to Disclose" form to prompt all users for an individual's full name prior to the system allowing the form to be marked as "completed" (Completed 5/23/2023). Due to the increase in our homeless population, Beacon Point is continuously collaborating with community-based resources in order to explore additional ongoing support for our clients who do not otherwise have an emergency contact available and/or those instances where a client does not know the full name of the individual in their support network.
Beacon Point's Director of Compliance has followed up with our Admissions Coordinator to discuss what provisions should be put in place at times when our EMR is down and/or unable to accept signatures. It has been confirmed this chart had hard copy consents signed due to an internet outage, however, as noted failed to have all elements present to make the consents valid.
Admissions department has been re-educated on the importance of signed valid consents (completed 5/22/2023) and any deviation from the established protocol needs to be approved by the Director of Compliance prior to completion of admission process.
Compliance officer will continue to conduct routine audits of all client charts to ensure this not an identified issue moving forward.
|
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.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of two applicable client records reviewed.Client # 6 was admitted to the inpatient non-hospital detoxification activity on November 14, 2022 and was administratively discharged on November 17, 2022. There was no documentation, in the record, indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Upon additional review of the referenced client chart, Beacon Point notes it was unsafe for on-site staff, at the time of discharge, to request this client sign the termination of treatment form as there were ongoing verbal threats of facility destruction and physical assault towards numerous staff which is delineated in the progress notes and emails surrounding this specific individuals Admin DC decision.
Beacon Point's Director of Compliance has digitized the "Administrative Discharge Appeal" form (completed 5/23/23) in an attempt to streamline this process moving forward. All appeal forms will be generated and maintained in the facility's EMR along with a progress note entry evidencing the circumstances at discharge. When noted it is unsafe for the client to be requested to sign Appeal form, BPR will mail a copy of form to the last known address of client unless chart evidences client was homeless at time of admission. Director of Compliance will complete monthly audits of charts with an "Administrative Discharge" status to ensure compliance moving forward.
|
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on review of the May 2022 through April 2023 unusual incident report logs, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire or ambulance personnel.On May 5, 2022, police, fire, or ambulance was called to the facility, and the facility had till May 10, 2022 to report the incident to the Department; however, it was reported on May 16, 2022.On May 22, 2022, police, fire, or ambulance was called to the facility, and the facility had till May 25, 2022 to report the incident to the Department; however, it was reported on June 2, 2022.On May 25, 2022, police, fire, or ambulance was called to the facility, and the facility had till May 30, 2022 to report the incident to the Department; however, it was reported on June 2, 2022.On February 14, 2023 and March 20, 2023, fire personnel were called to the facility; however, the incident was not reported to the Department at the time of inspection.This is a repeat citation from the April 29, 2022 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has reviewed the recently updated Incident reporting policy which includes the reporting of applicable unusual incidents to the Department within (3) business days, and it has been noted these reports will be completed by the Director of Compliance via DDAP's online incident reporting portal for all applicable incidents moving forward. A finalized copy of all submitted reports will be maintained by Compliance Department for review during quarterly QA meetings to discuss any trends identified. External incident reporting will be audited bi-weekly by Compliance Department to ensure any needed areas of improvement are noted and/or barriers to reporting are discussed with Leadership team during quarterly QA meetings.
As of the date this POC is submitted, Beacon Point has received an exception for any instance where police, fire, or ambulance respond to the campus address but do not have any interaction with Beacon Point clients or staff. The instances noted in this citation for dates 2/14/2023 and 3/20/2023 hereby fall under the exception granted by DDAP.
|
709.63(a)(6) LICENSURE Aftercare plan
709.63. 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:
(6) Aftercare plans, if applicable.
|
Observations
Based on a review of client records, the facility failed to document the aftercare plan in one of three applicable client records reviewed.The policy and procedure manual stated the aftercare plan is to be completed at discharge for successful discharges. Client #7 was admitted to the inpatient non-hospital detoxification activity on March 8, 2023 and was successfully discharged on March 15, 2023. The aftercare plan was completed on May 15, 2023.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has reviewed the applicable regulation verbiage with the facility's Clinical Director who subsequently held a group supervision with all clinical team members on 5/24/23 to review cited information. Compliance Department will continue to conduct bi-weekly audits until 100% satisfaction is noted, then audits will resume monthly. Results of all audits completed will be discussed with department leads in real time as well as reviewed with entire Leadership team during quarterly QA meetings. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in two of four applicable client records reviewed.Client # 6 was admitted to the inpatient non-hospital detoxification activity on November 14, 2022 and was discharged on November 17, 2022. The record did not include follow-up information at the time of the inspection.Client # 7 was admitted to the inpatient non-hospital activity on March 8, 2023 and was discharged on March 15, 2023. The record did not include follow-up information at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has updated the applicable policy to reflect all Follow Up calls will be made by a member of the Compliance Department, which was effective 5/1/2023. Director of Compliance has added a "Progress Note" category to Beacon Point's EMR which highlights the "Follow Up" progress notes versus any other progress note in the chart which will assist in the audit process moving forward. Chart audits will be completed on a bi-weekly basis until 100% satisfaction is achieved at which point the audit for these specific notes will decrease to monthly. Results of all audits completed will be discussed with department leads in real time as well as reviewed with entire Leadership team during quarterly QA meetings. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation, as part of their intake process and per the project ' s policy and procedure manual, in three of seven applicable client records reviewed. The facility policy and procedure manual states that the psychosocial evaluation is to be completed within 5 days of admission.Client # 8 was admitted to the inpatient non-hospital activity on February 9, 2023 and was still active at the time of the inspection. The psychosocial evaluation was due to be completed on February 14, 2023; however, the evaluation was not completed until February 15, 2023. Client # 11 was admitted to the inpatient non-hospital activity on May 2, 2022 and was discharged on June 6, 2022. The psychosocial evaluation was due to be completed on May 7, 2022; however, the evaluation was not completed until May 9, 2022. Client # 12 was admitted to the inpatient non-hospital activity on August 1, 2022 and was discharged on October 4, 2022. The psychosocial evaluation was due to be completed on August 6, 2022; however, the evaluation was not completed until August 11, 2022. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has updated the applicable facility protocol to delineate a clinician's responsibility in the event a client is said to be ill and unable to complete the required assessment within the timeframe previously established. If a client refuses to meet with the clinician to complete the biopsychosocial assessment per facility policy, citing they are too ill, they will be required to meet with the unit nurse for confirmation.
Documentation of this encounter will be found within the client's chart (both Nursing and Clinical will document their respective interactions). When appropriate, the clinician will send correspondence to the facility's Clinical Director, Lead Nurse, and Director of Compliance to request an extension of time in which to complete the required assessment.
Each request will be evaluated on a case-by-case basis and no extension issued shall exceed (48) hours from the date it would have otherwise been due.
Compliance department will monitor this protocol adjustment and document efficacy (or lack thereof), reporting such findings to Leadership team during quarterly QA meetings. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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.
|
Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in four of four applicable client records reviewed.Client # 11 was admitted to the inpatient non-hospital activity on May 2, 2022 and was discharged on June 6, 2022. The record did not include follow-up information at the time of the inspection.Client # 12 was admitted to the inpatient non-hospital activity on August 1, 2022 and was discharged on October 4, 2022. The record did not include follow-up information at the time of the inspection.Client # 13 was admitted to the inpatient non-hospital activity on September 3, 2022 and was discharged on September 26, 2022. The record did not include follow-up information at the time of the inspection.Client # 14 was admitted to the inpatient non-hospital activity on July 1, 2022 and was discharged on July 30, 2022. The record did not include follow-up information at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has updated the applicable policy to reflect all Follow Up calls will be made by a member of the Compliance Department, which was effective 5/1/2023. Director of Compliance has added a "Progress Note" category to Beacon Point's EMR which highlights the "Follow Up" progress notes versus any other progress note in the chart which will assist in the audit process moving forward. Chart audits will be completed on a bi-weekly basis until 100% satisfaction is achieved at which point the audit for these specific notes will decrease to monthly. Results of all audits completed will be discussed with department leads in real time as well as reviewed with entire Leadership team during quarterly QA meetings. |
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.
|
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 failing to document annual written individual staff performance evaluations reviewed and signed by the employee was submitted and approved by the Department for the April 29, 2022 and May 25, 2021 annual licensing inspections. Failing to document annual written individual staff performance evaluations reviewed and signed by the employee was again found to be a deficiency in the May 15, 2023 through May 17, 2023 licensing inspection. A plan for correction for failing to document an annual written individual training plan for each employee with input from both the employee and the supervisor was submitted and approved by the Department for the April 29, 2022 and May 25, 2021 annual licensing inspection. Failing to document an annual written individual training plan for each employee with input from both the employee and the supervisor was again found to be a deficiency in the May 15, 2023 through May 17, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beacon Point's Director of Compliance has reviewed all available information pertaining to this citation with facility's Leadership team. It is noted our facility has experienced a substantial amount of turnover in the preceding (3) years which has allowed for this to happen on more than one occasion. Approved plan of correction has been reviewed with Leadership and Executive teams to ensure no deviations take place moving forward (completed 5/29/23). Director of Compliance has updated the established auditing schedule in order to account for deficiencies faster and results of all audits will be discussed with entire Leadership team during quarterly QA meetings in order to put provisions in place in real time. |