D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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BEYOND ADDICTION RECOVERY AND TREATMENT CENTER LLC
219 WELLWOOD DRIVE
TUNKHANNOCK, PA 18657

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Survey conducted on 03/19/2026

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on March 19, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Beyond Addiction Recovery and Treatment 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
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.
Observations Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven records reviewed.Client #1 was admitted to the inpatient program on January 9, 2026 and was discharged March 2, 2026. The facility failed to obtain releases of information forms for the family members that participated in family counseling sessions that took place on January 28, 2026, February 8, 2026, February 15, 2026, and February 22, 2026. Client #5 was admitted to the inpatient program on February 2, 2026 and was active at the time of the licensing process. The facility failed to obtain releases of information forms for the family members that participated in family counseling sessions that were documented in case consultation notes dated March 18, 2026.Client #7 was admitted to the inpatient program on January 29, 2026 and was active at the time of the licensing process. The facility failed to obtain a release of information form for the funding source until February 5, 2026, and the facility confirmed billing had taken place starting January 29, 2026. These findings were reviewed with project staff during the licensing process.	Plan of Correction Deficiency Identified: The facility did not consistently ensure that a valid consent to disclose information form was completed and signed by the client prior to releasing information to outside parties. Corrective Action Plan: Effective immediately, the facility will implement a standardized protocol to ensure that no client information is disclosed without a properly executed and valid consent to disclose form. Process for Compliance: Consent Requirement Prior to Disclosure: Staff are strictly prohibited from releasing any client information without verifying that a current, signed consent to disclose form is present in the client's chart. The consent must include all required elements, including the specific party, type of information to be disclosed, purpose, and expiration date. Responsibility for Obtaining Consents: Primary Counselors will be responsible for obtaining all necessary consent to disclose forms during the intake process and prior to any disclosure. In the absence of the Primary Counselor, the assigned Case Manager or covering clinician will be responsible. Verification Process: Prior to any communication with outside parties, staff must verify the presence of a valid consent form in the EMR system. A checklist will be added to the client record in the EMR (KIPU) requiring confirmation of consent before documentation of any external communication. Training and Re-Education: The Chief Clinical Officer (CCO) will conduct a mandatory training for all clinical and administrative staff on confidentiality requirements and proper use of consent to disclose forms. Training will include: Review of facility policy and applicable confidentiality regulations (including 42 CFR Part 2, if applicable) Step-by-step instruction on completing and verifying consent forms Scenarios illustrating compliant vs. non-compliant disclosures Training Date: 4/8/2026 Ongoing Training: Incorporated into new hire orientation and annual refresher trainings Attendance will be documented and maintained in personnel files. Monitoring and Quality Assurance: Ongoing Monitoring Responsibility: The CCO and Utilization Review (UR) Specialist will be responsible for ongoing compliance monitoring. Audit Process: Weekly chart audits will be conducted to ensure: A valid consent to disclose form is present prior to any documented external communication Consents are properly completed and not expired Corrective Measures: Any identified deficiencies will result in: Immediate staff re-education Documentation of the issue and corrective action taken Progressive disciplinary action if repeated non-compliance occurs Tracking and Documentation: Audit results will be tracked and reviewed monthly by CEO to identify trends and ensure sustained compliance.
709.32 (c) (6) LICENSURE Medication control § 709.32. Medication control. (6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
Observations Based on the review of client records, the project failed to ensure medication errors and drug reactions are recorded in the client record in one out of seven records reviewed.Client #4 was admitted to the inpatient program on January 7, 2026 and was discharged on January 21,2026. The client was prescribed Buspirone 5mg, one tab three times a day; however, on January 14, 2026, January 15, 2026, January 16, 2026, January 17, 2026, January 18, 2026, and January 19, 2026, there was no documentation identifying the reason the third dose of the medication was not administered on those days. These findings were reviewed with project staff during the licensing process.	Plan of Correction Nurse Practitioner implemented a new policy on 3/30/2026 that all medication will be labeled as Did Not Show (DNS) on the medication log if the client does not come to the medication times that are prescribed by the provider. This process will be overseen by Beyond Addiction's NP and oversight will be monitored weekly by CEO.
709.53(a)(5) LICENSURE Progress Notes 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: (5) Progress notes.
Observations Based on a review of inpatient client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project, that included progress notes completed within seven days of a session, per facility policy, in six of seven records reviewed.Client #1 was admitted to the inpatient program on January 9, 2026 and was discharged March 2, 2026. The record contained progress notes for individual sessions occurring on January 11, 2026, and February 5, 2026, that were not completed until January 31, 2026, and February 17, 2026. Additionally, the record contained a progress note for a group session occurring on February 17, 2026, that was not documented until March 3, 2026.Client #3 was admitted to the inpatient program on December 1, 2025 and was discharged January 13, 2026. The record contained progress notes for group sessions occurring on December 28, 2025, December 30, 2025, January 10, 2026, and January 12, 2026, that were not completed until March 3, 2026, March 1, 2026 and January 26, 2026.Client #4 was admitted to the inpatient program on January 7, 2026 and was discharged on January 21,2026. The record contained progress notes for group sessions occurring on January 11, 2026, January 18, 2026 and January 20, 2026, that were not completed until March 3, 2026, and March 1, 2026.Client #5 was admitted to the inpatient program on February 2, 2026 and was active at the time of the licensing process. The record contained progress notes for group sessions occurring on February 5, 2026, February 6, 2026, February 8, 2026, February 12, 2026, February 13, 2026, February 14, 2026, February 16, 2026, February 17, 2026, February 21, 2026, and February 27, 2026, that were not completed until March 3, 2026, March 1, 2026, March 19, 2026, and March 18, 2026 respectively. Client #6 was admitted on December 26, 2025, and was active at the time of the licensing process. The record contained progress notes for group sessions occurring on December 30, 2025, January 1, 2026, January 3, 2026, January 4, 2026, January 8, 2026, January 10, 2026, January 11, 2026, January 12, 2026, January 14, 2026, January 15, 2026, January 18, 2026, January 20, 2026, January 21, 2026, January 22, 2026, January 23, 2026, January 27, 2026, January 29, 2026, February 3, 2026, February 5, 2026, February 6, 2026, February 8, 2026, February 12, 2026, February 13, 2026, February 14, 2026, February 16, 2026, February 17, 2026, and February 23, 2026, that were not completed until March 3, 2026, March 1, 2026, January 26, 2026, February 19, 2026, February 1, 2026, February 19, 2026, February 3, 2026, March 18, 2026, and February 18, 2026, respectively. Client #7 was admitted to the inpatient program on January 29, 2026 and was active at the time of the licensing process. The record contained progress notes for group sessions occurring on February 3, 2026, February 6, 2026, February 8, 2026, February 16, 2026, February 17, 2026, February 21, 2026, February 27, 2026, and March 7, 2026, that were not completed until March 1, 2026, March 3, 2026, , March 18, 2026, and March 19, 2026, respectively. These findings were reviewed with project staff during the licensing process.This is a repeat citation from April 2, 2025, and September 29, 2025 licensing inspection.	Plan of Correction Deficiency Identified: Progress notes were not consistently completed within the required policy time frame. Corrective Action: Beyond Addiction will ensure that all progress notes are completed within the established policy time frame through structured training, ongoing monitoring, and staff accountability measures. Training and Education Plan: All clinical staff (counselors and case managers) will receive mandatory re-education on the agency's Progress Note Policy. This training will include: A detailed review of documentation timeframes and expectations Step-by-step instruction on proper completion of progress notes in the KIPU EMR system Clarification of what constitutes a compliant and complete progress note Review of common errors and how to avoid them Instructions on how to track and manage documentation deadlines Who Will Provide Training: The training will be conducted by the Chief Clinical Officer (CCO) in collaboration with the Utilization Review (UR) Specialist. Training Timeline: Initial mandatory training will be completed by all current clinical staff no later than 4/7/2026. Any new hires will receive this training during orientation before assuming documentation responsibilities Staff who fail to meet compliance standards will receive additional one-on-one retraining as needed within 5 days of identified deficiency Ongoing Monitoring and Compliance: The CCO and UR Specialist will conduct weekly chart audits to ensure progress notes are completed within the required timeframe Counselors will utilize Microsoft Calendar reminders and tracking tools to manage documentation deadlines A documentation tracking log will be implemented to monitor timeliness Accountability Measures: Staff not meeting compliance will receive corrective action, including retraining and increased supervision Continued noncompliance may result in disciplinary action per agency policy Follow-Up and Sustainability: Monthly documentation compliance reports will be reviewed by CEO. Feedback will be provided to staff during supervision sessions The training program will be reviewed quarterly to ensure effectiveness and updated as needed
709.53(a)(8) LICENSURE Case Consultation Notes 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: (8) Case consultation notes.
Observations Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes in seven out of seven records reviewed.The facility had case consultation notes; however, they failed to document who the consultation was with in all seven records reviewed.This finding was reviewed with facility staff during the licensing process.	Plan of Correction Plan of Correction (POC) The CCO has implemented a new form in KIPU (the EMR system utilized by Beyond Addiction) that will clearly list all parties present for Case Consult meetings. In addition, the involvement of the client in the Case Consult process will be thoroughly explained and documented to ensure compliance moving forward. This process will be overseen by the CCO and monitored by the CEO. Staff Training Plan: All clinical staff, including counselors and case managers, will be retrained on the proper use of the new Case Consult form and the requirements for documenting all parties present and client involvement. The training will include a step-by-step walkthrough of the new form in KIPU, documentation expectations, and clarification of the facility policy related to Case Consult meetings. The training will be conducted by the CCO. A mandatory group training session will be held on April 3, 2026, prior to implementation of the new process. Any staff who are unable to attend the group training will receive one-on-one re-education from the CCO within one week of the training date. All new hires will receive this training during orientation moving forward. Monitoring and Compliance: The CCO will review charts weekly to ensure the new form is being completed correctly and that client involvement is properly documented. The CEO will monitor compliance with this corrective action to ensure the process is consistently followed.
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 have a complete client record on an individual which includes information relative to the client's involvement with the project, including follow up information within 7 days of discharge, per facility policy, in three out of four applicable records reviewed. Client #1 was admitted to the inpatient program on January 9, 2026 and was discharged March 2, 2026. The follow up was due March 9, 2026; however, no follow up was documented at the time of the licensing inspection. Client #2 was admitted to the inpatient program on December 8, 2025 and was discharged January 28, 2026. The follow up was due February 4, 2026; however, no follow up was documented at the time of licensing inspection.Client #4 was admitted to the inpatient program on January 7, 2026 and was discharged on January 21, 2026. The follow up was due January 28, 2026; however, no follow up was documented at the time of licensing inspection.These findings were reviewed with facility staff during the licensing process.	Plan of Correction Plan of Correction (POC) To ensure compliance with documentation and follow-up requirements, the facility will implement the following corrective actions: Corrective Action: Follow-ups for all referenced clients will be completed in a timely manner and properly documented in each client's chart. The facility has hired an Alumni Coordinator, who is scheduled to begin employment on April 6, 2026. The Alumni Coordinator will be responsible for completing follow-up contacts with former clients and ensuring that all follow-ups are accurately documented and maintained in the client record. 📋 Implementation Date: Follow-up procedures will begin immediately, and full implementation will occur once the Alumni Coordinator starts on 4/6/2026. Monitoring Plan: The CEO will monitor compliance to ensure that all follow-ups are completed and documented appropriately. The CEO will review documentation on an ongoing basis to confirm that follow-ups are being completed consistently and filed in the client's chart. Sustainability Plan: The Alumni Coordinator will maintain a tracking system for follow-ups to ensure they are completed within 7 days of the completed contact or outreach to alumni. Ongoing oversight by the CEO will ensure continued compliance and proper documentation moving forward.
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 to ensure a complete client record included information relative to the client's involvement with the project to include progress notes entered within seven days of the date of service, was submitted and approved by the Department for the April 2,2025, and September 29, 2025, annual licensing inspection. Entering progress notes into the client record within seven days from the date of service was again found to be a deficiency during the March 19, 2026, licensing inspection.These findings were reviewed with facility staff during the licensing process.	Plan of Correction Other: Failure to Follow Previously Approved Plans of Correction Beyond Addiction acknowledges that previously approved Plans of Correction were not consistently followed. This was not due to unwillingness to comply, but primarily due to significant staff turnover and lack of consistent training processes during that time. As a result, previously implemented corrective actions were not carried out as intended and documentation timelines were not consistently maintained. To correct this issue and prevent it from happening again, the CCO implemented a formal training protocol on 3/30/2026 for all counselors and case managers. This training focused specifically on timely input of documentation, adherence to established corrective actions, and accountability for following approved Plans of Correction. As part of this process, a seamless timeline sheet was created and distributed to all counselors and case managers to ensure they clearly understand required timeframes for progress notes, documentation, and follow-ups. In addition, the CCO and UR Specialist will monitor charts weekly to ensure timely input of progress notes and documentation. This weekly monitoring will allow issues to be identified immediately and corrected before they become ongoing compliance concerns. Counselors will also utilize the Microsoft Calendar to set reminders and ensure progress notes and documentation are completed within required timeframes. The CCO will oversee and monitor this process to ensure full compliance moving forward. These corrective actions directly address the facility's previous inability to follow approved Plans of Correction by implementing structured training, clear timelines, and consistent weekly monitoring to ensure compliance is maintained long-term.