INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection monitoring conducted on April 28, 2022 through April 29, 2022 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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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.
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Observations
Based on a review of personnel records, the facility failed ensure that all counselors met the appropriate qualifications for the position in one of five applicable personnel records reviewed.Employee #9 was hired as a counselor on January 25, 2021. The employee had full CADC certification as an addictions counselor by a statewide certification body; however, the certification expired, and was not renewed, on February 11, 2022 and the employee does not have a qualifying degree. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Beacon Point has reviewed the credentials with the employee referenced and the CADC has been reapplied for on 5/31/2022. Beacon Point's HR representative will continue to monitor all clinical staff to ensure we do not experience a lapse in credentialing moving forward and report inconsistencies to Clinical Director and Director of Compliance during the facility's quarterly QA meetings. |
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.
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Observations
Based on a review of personnel records, the facility failed to document an annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in nine of fourteen personnel records reviewed. Employee # 2 was hired as the Facility Director on November 25, 2019. There was no current individual training plan documented in the record at the time of the inspection.Employee # 4 was hired as a clinical supervisor on March 17, 2022. There was no current individual training plan documented in the record at the time of the inspection.Employee # 5 was hired as a counselor on November 12, 2021. There was no current individual training plan documented in the record at the time of the inspection.Employee # 6 was hired as a counselor on April 29, 2021. There was no current individual training plan documented in the record at the time of the inspection.Employee # 8 was hired as a counselor on September 20, 2021. There was no current individual training plan documented in the record at the time of the inspection.Employee # 10 was hired as a counselor assistant on December 20, 2021. There was no current individual training plan documented in the record at the time of the inspection.Employee # 11 was hired as a counselor assistant on January 3, 2022. There was no current individual training plan documented in the record at the time of the inspection.Employee # 12 was hired as a counselor assistant on January 31, 2022. There was no current individual training plan documented in the record at the time of the inspection.Employee # 14 was hired as a counselor assistant on March 29, 2022. There was no current individual training plan documented in the record at the time of the inspection.This is a repeat citation from the May 25, 2021 licensing inspection.These findings were reviewed with facility staff during the licensing inspection.
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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 on year 2021 as well as trainings they are interested in completing this calendar year. All active employees, except those otherwise delineated in the regulations, have been asked to complete (12) hours of applicable training. All Training Plans are signed by the employee as well as their direct supervisor and kept on file with Human Resources. All completed forms are to be on file no later than June 30, 2022. HR representative will conduct quarterly audits of personnel files for all active and new employees, providing an updated status of outstanding Training Plan completions during QA meetings with Leadership.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the facility director completed at least 12 clock hours of training during the facility's January 1, 2021 through December 31, 2021 training year.Employee #2 was hired as the Facility Director on November 25, 2019. The personnel record documented 0 hours of training during the 2021 training year. This is a repeat citation from the May 25, 2021 licensing inspection.This finding was 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 regulations with the Facility Director (signed 5/2/22) and a Training Plan has been completed which details how he plans to obtain the required number of hours prior to the end of this calendar year. Provisions have been put into place to avoid this being an issue moving forward which includes quarterly reporting by HR of submitted training hours to Director of Compliance.
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that each clinical supervisor completed at least 12 clock hours of training annually during the facility's January 1, 2021 through December 31, 2021 training year in one of one applicable personnel record reviewed.Employee # 3 was hired as a clinical supervisor on October 21, 2019. The personnel record documented 6.5 hours of training received during the reviewed training year. This is a repeat citation from the May 25, 2021 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's Director of Compliance has reviewed the regulations with the Clinical
Director and had them complete a Training
Plan (signed 5/2/22) which details how they plan to obtain the required number of hours prior to the end of this calendar year. Provisions have been put into place to avoid this being an issue moving forward which includes quarterly reporting by HR of submitted training hours to Director of Compliance.
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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.
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Observations
Based on a physical plant inspection conducted on April 28, 2022 between 11:00 AM and 12:00 PM, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. Electrical outlets in the bathrooms of rooms 401, 404, 405, 506, 508, 608, 612, 613, 708, 710, 711, 712 and 713 were burnt, posing an electrical safety hazard. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has collaborated with our property manager to organize the replacement of the outlets in rooms 401, 404, 405, 506, 508, 608, 612, 613, 708, 710, 711, 712, and 713. This is projected to be completed no later than 6/30/22. Beacon Point's Operations Department is conducting weekly room inspections of all client rooms moving forward to ensure all items required are present, operable, and safe. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's financial audit is currently pending with an independent certified public accountant and is anticipated to be completed no later than 6/30/2022.
Beacon Point's CFO will facilitate the completion of the facility's financial audit to ensure it is completed no later than the end of the 1st quarter annually moving forward. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, the facility failed to document the written verification of qualifying professional credentials in one of fourteen applicable personnel records reviewed.Employee # 8 was hired as a counselor assistant on January 14, 2022. There was no documentation of the qualifying professional credentials in the record at the time of the inspection. The personnel record included a copy of a college diploma that was unreadable, as well as a transcript that did not indicate that a degree was conferred.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's HR representative has requested the employee referenced to obtain a more legible copy of their credentials in order to update our personnel file. This is anticipated to be received no later than 6/15/2022. HR representative and Director of Compliance will review credentials received for all clinical new-hires moving forward to ensure they are legible and acceptable according to the applicable regulations. |
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.
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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 five of five applicable personnel records reviewed. Employee # 1 was hired as the Project Director on March 1, 2019. The annual written performance evaluation was completed on October 7, 2021; however, the evaluation was not reviewed and signed by the employee at the time of the inspection. Employee # 2 was hired as the Facility Director on November 25, 2019. The annual written performance evaluation was completed on October 7, 2021; 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 October 21, 2019. The annual written performance evaluation was completed on December 16, 2021; however, the evaluation was not reviewed and signed by the employee at the time of the inspection. Employee # 6 was hired as a counselor on April 29, 2021. The written performance evaluation did not document the date it was completed, and it was not reviewed and signed by the employee, at the time of the inspection. Employee # 9 was hired as a counselor on January 25, 2021. The written performance evaluation did not document the date it was completed, and it was not reviewed and signed by the employee, at the time of the inspection. This is a repeat citation from the May 25, 2021 annual licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has updated all evaluation forms to include those elements listed in this citation. Provisions have been put in to place so each department supervisor will ensure the employee name, date completed, date acknowledged, date uploaded, employee signature, and supervisor signature are obtained on all performance evaluations completed moving forward. Beacon Point's HR representative will review each performance review as they are finalized for compliance prior to placing in personnel files. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility's May 2021 through April 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident at the facility of a physical assault involving clients on February 14, 2022This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has updated its Incident Reporting policy to include the reporting of unusual incidents to the Department within (3) business days and will be completed by the Compliance department via DDAP's online incident reporting portal for all applicable incidents moving forward. Incident reporting will be audited monthly to ensure facility compliance and any areas of improvement noted will be discussed during quarterly QA meetings with Leadership. |
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.
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Observations
Based on a review of the facility's May 2021 through April 2022 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an event that required the presence of police, fire, or ambulance personnel at the facility on November 13, 2021.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has updated its Incident Reporting policy to include the reporting of incidents which involve the presence of police, fire or ambulance personnel to the Department within (3) business days and will be completed by the Compliance department via DDAP's online incident reporting portal for all applicable incidents moving forward. Incident reporting will be audited monthly to ensure facility compliance and any areas of improvement noted will be discussed during quarterly QA meetings with Leadership. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include a discharge summary, in two of four applicable records reviewed.Client #11 was admitted to the inpatient non-hospital activity on January 19, 2022 and discharged on February 14, 2022. The client record did not document a discharge summary at the time of the inspection.Client #12 was admitted to the inpatient non-hospital activity on December 28, 2021 and discharged on February 14, 2022. The client record did not document a discharge summary at the time of the inspection.This is a repeat citation from the May 25, 2021 annual licensing inspection.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical staff have been reminded during a training held on 5/3/2022 all discharge summaries are due to be in the clinical chart within (10) days of the client's date of discharge. Internal audits will be conducted by Compliance officer bi-weekly to ensure ongoing compliance with this regulation. Results of audits will be discussed during quarterly QA meetings in order to address any areas of improvement and/or offer additional support where needed.
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