INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on November 7, 2023 through November 8, 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:
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Plan of Correction
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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.
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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 five 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 #7 was admitted to the inpatient non-hospital detoxification activity on October 30, 2023 and was discharged against medical advice on November 1, 2023. 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 # 12 was admitted to the inpatient non-hospital activity on August 19, 2023 and was discharged against medical advice on September 1, 2023. 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.
This is a repeat citation from the May 17, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's Director of Compliance has reviewed the applicable regulation with all department heads to ensure staff are reminded to continue contacting the EC for each abnormal discharge, when a valid consent is present. Staff involved in the crisis will continue to include this information in the progress notes they enter in our EMR for the client, as well as note who they contacted on the facility's internal SIR form. Beacon Point's compliance department will continue to conduct daily audits of discharged client charts to ensure documentation is present of EC being contacted in all cases where there is a valid consent present, with weekly audit summaries being sent weekly to documented progress. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in three of twenty-five client records reviewed.
Client # 1 was admitted to the inpatient non-hospital detoxification activity on September 5, 2023 and was discharged on September 10, 2023. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 15 was admitted inpatient non-hospital activity on September 11, 2023 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, the release of information form was not signed by the client until November 8, 2023. There was no valid consent to release information form for any disclosures to the funding source from September 11, 2023 through November 7, 2023.
Client #23 was admitted to the inpatient non-hospital activity on August 9, 2023 and was discharged on August 13, 2023. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's Director of Compliance has continued to re-educated the Admissions department 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. |