INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on April 29, 2024 through May 1, 2024 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 to ensure counselors met the appropriate qualifications for the position in two of seven 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 when hired; however, the certification expired on February 11, 2024 and was not renewed. The employee currently does not have a qualifying degree.
Employee #13 was hired as a high school diploma/GED-level counselor assistant on December 20, 2021 and was promoted to a counselor on December 19, 2023. At the time of the promotion, the employee did not have a qualifying degree or certification qualification for the position of counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since the date of inspection, Employee #9 has received full CADC certification, good until 2/11/2026. An exception is pending review with DDAP at this time. Moving forward, Employee will be notified (3) months in advance of expiration date to ensure renewal is completed prior to annual licensing inspection.
Since the date of inspection, Employee #13 has been demoted back to Counselor Assist until a qualifying degree is obtained and/or certification. Beacon Point is assisting this employee with applying for a state recognized certification and will ensure either are present prior to the annual licensing inspection.
Beacon Point has reviewed credentialing requirements with our Hiring Department to ensure moving forward our facility remains in line with the appropriate regulatory requirements for all employees. There will be routine audits completed by our newly appointed Recruitment Coordinator to ensure compliance with all applicable regulations.
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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.
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Observations
Based on a review of personnel records, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in two of three applicable personnel record reviewed.
Employee #7 was hired as a counselor on April 17, 2023 and was due to receive at least four hours of TB/STD training no later than April 17, 2024; however, there was no documentation of the completion of at least 4 hours of TB/STD training at the time of the inspection.
Employee #16 was hired as a counselor assistant on April 10, 2023 and was due to receive at least 4 hours of TB/STD training no later than April 10, 2024; however, there was no documentation of the completion of at least 4 hours of TB/STD training at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Beacon Point received additional clarification from our licensing specialist during the annual licensing inspection and is currently working with our training provider, MedTrainer, to provide this training to all employees, making the curriculum available for review at our inspection.
Beacon Point's People Operations department is reviewing the applicable regulations to ensure our training offering is in line with all needed requirements. Beacon Point's corporate Director of Compliance and Licensing has also communicated with our training provider, MedTrainer, who has been able to bundle training courses in line with the requirements of DDAP to ensure ongoing completion and compliance moving forward.
BPR Director of Compliance and corporate Director of Compliance & Licensing in collaboration with People Operations department will conduct monthly audits of staff training hours completed to ensure needed trainings are being completed within the timeframes established. |
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.
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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 2023 through December 2023 training year in two of three applicable personnel record reviewed.
Employee #5 was hired as a counselor on September 6, 2022. The personnel record documented 14 hours of annual training during the reviewed period.
Employee #9 was hired as a counselor on January 25, 2021. The personnel record documented 8 hours of annual training during the reviewed period.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Beacon Point has completed supervision with the applicable employees to re-educate them on the regulatory requirements for annual CEU training as dictated by their position. Employees have acknowledged this education and BPR will follow acquired hours for all applicable employees to ensure regulatory compliance moving forward. BPR Clinical Director will conduct quarterly audits of training hours acquired to ensure all staff are consistently working towards meeting annual requirements. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon staff employment in four of seven applicable personnel records reviewed.
Employee #1 was hired as the project director on August 28, 2023. There was no documentation of the employee receiving fire extinguisher training as of the date of the inspection.
Employee #4 was hired as a counselor on March 25, 2024. There was no documentation of the employee receiving fire extinguisher training as of the date of the inspection.
Employee #11 was hired as a counselor on July 10, 2023. There was no documentation of the employee receiving fire extinguisher training as of the date of the inspection.
Employee #12 was hired as a counselor on March 18, 2024. There was no documentation of the employee receiving fire extinguisher training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point offers every employee annual core competency training and will have a certificate generated moving forward which will delineate all topics covered, inclusive of Fire Extinguisher training. The curriculum of this training will be available upon request during all upcoming annual inspections. BPR Director of Compliance in collaboration with People Operations department will ensure all staff are offered this training during on-boarding and annually thereafter. BPR Director of Compliance will conduct routine audits of on-site personnel files to ensure certificates of completion are present for each staff member on active roster. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel, on all shifts, are trained to perform assigned tasks during emergencies in four of seven applicable personnel records reviewed.
Employee #1 was hired as the project director on August 28, 2023. There was no documentation of the employee receiving emergency preparedness training as of the date of the inspection.
Employee #4 was hired as a counselor on March 25, 2024. There was no documentation of the employee receiving emergency preparedness training as of the date of the inspection.
Employee #11 was hired as a counselor on July 10, 2023. There was no documentation of the employee receiving emergency preparedness training as of the date of the inspection.
Employee #12 was hired as a counselor on March 18, 2024. There was no documentation of the employee receiving emergency preparedness training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point offers every employee annual core competency training and will have a certificate generated moving forward which will delineate all topics covered, inclusive of Emergency Preparedness training. The curriculum of this training will be available upon request during all upcoming annual inspections.
BPR Director of Compliance in collaboration with People Operations department will ensure all staff are offered this training during on-boarding and annually thereafter. BPR Director of Compliance will conduct routine audits of on-site personnel files to ensure certificates of completion are present for each staff member on active roster. |
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 eight of twenty-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. Additionally, the manual stated that the preliminary treatment plan is to be completed within 24 hours of admission. Also, the manual stated that the discharge summary is to be completed within 10 days of discharge.
Client # 1 was admitted to the inpatient non-hospital detoxification activity on November 10, 2023 and was discharged against medical advice on November 14, 2023. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice at the time of the inspection.
Client # 8 was admitted to the inpatient non-hospital activity on April 23, 2024 and was still active at the time of the inspection. The preliminary treatment plan was due to be completed no later than April 24, 2024; however, the plan was completed on April 25, 2024.
Client # 10 was admitted to the inpatient non-hospital activity on March 10, 2024 and was discharged on March 18, 2024. The preliminary treatment plan was due to be completed no later than March 11, 2024; however, the plan was completed on March 12, 2024.
Client # 12 was admitted to the inpatient non-hospital activity on December 15, 2023 and was discharged on December 19, 2023. The discharge summary was due to be completed no later than December 29, 2023; however, the summary was completed on February 9, 2024.
Client # 13 was admitted to the inpatient non-hospital activity on December 28, 2023 and was discharged on December 30, 2023. The discharge summary was due to be completed no later than January 9, 2024; however, the summary was completed on February 6, 2024.
Client # 14 was admitted to the inpatient non-hospital activity on January 6, 2024 and was discharged on January 10, 2024. The discharge summary was due to be completed no later than January 20, 2024; however, the summary was completed on February 9, 2024.
Client # 15 was admitted to the inpatient non-hospital activity on February 2, 2024 and was still active at the time of the inspection. The preliminary treatment plan was due to be completed no later than February 3, 2024; however, the plan was completed on February 5, 2024.
Client # 16 was admitted to the inpatient non-hospital activity on February 8, 2024 and was still active at the time of the inspection. The preliminary treatment plan was due to be completed no later than February 9, 2024; however, the plan was completed on February 10, 2024.
This is a repeat citation from the May 17, 2023 annual licensing inspection and the November 8, 2023 provisional license follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has re-educated all staff on the policy timelines established via a clinical department case conference meeting and will closely monitor the completion of the referenced documents via daily chart audits completed by Clinical Director and Clinical Supervisor to ensure timely completion. Beacon Point will continuously monitor staff who struggle to complete documentation and offer coaching to those who exhibit a trend. |
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 eighteen applicable client records reviewed.
Client # 4 was admitted to the inpatient non-hospital detoxification activity on April 26, 2024 and was still active at the time of the inspection. There was documentation 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 # 10 was admitted to the inpatient non-hospital activity on March 10, 2024 and was discharged on March 18, 2024. The client's funding source changed on March 12, 2024 and there was evidence of disclosures to the new 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 to the new funding source.
Client # 16 was admitted to the inpatient non-hospital activity on February 8, 2024 and was still active at the time of the inspection. The client's funding source changed on March 11, 2024 and there was evidence of disclosures to the new 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 to the new funding source.
This is a repeat citation from the November 8, 2023 provisional license follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has implemented an internal process to ensure when a client's funding source changes for any reason, there is immediate completion of any and all applicable authorizations to ensure moving forward no unauthorized disclosures are made. This process is being monitored by the Director of Compliance to ensure strict adherence. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician document whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance during the initial face-to-face meeting in seven of eight applicable patient records reviewed.
Patient # 8 was admitted to the inpatient non-hospital activity on April 23, 2024 and was still active at the time of the inspection. The physician's verification of dependency, dated April 24, 2024, did not document that the patient has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
Patient # 9 was admitted to the inpatient non-hospital activity on December 11, 2023 and was discharged on December 18, 2023. The physician's verification of dependency, dated December 12, 2023, did not document that the patient is currently physiologically dependent has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
Patient # 10 was admitted to the inpatient non-hospital activity on March 10, 2024 and was discharged on March 18, 2024. The physician's verification of dependency dated March 11, 2024, did not document that the patient has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
Patient # 11 was admitted to the inpatient non-hospital activity on December 3, 2024 and was discharged on December 7, 2023. The physician's verification of dependency, dated December 4, 2023, did not document that the patient has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
Patient # 12 was admitted to the inpatient non-hospital activity on December 15, 2023 and was discharged on December 19, 2023. The physician's verification of dependency, dated December 16, 2023, did not document that the patient has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
Patient # 13 was admitted to the inpatient non-hospital activity on December 28, 2023 and was discharged on December 30, 2023. The physician's verification of dependency was only signed by a clinical supervisor on December 29, 2023 and did not document that the physician determined that patient is currently physiologically dependent has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
Patient # 14 was admitted to the inpatient non-hospital activity on January 6, 2024 and was discharged on January 10, 2024. The physician's verification of dependency, dated January 17, 2024, did not document that the patient has been physiologically dependent for at least 1 year prior to admission for maintenance treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has met with the Medical Director to ensure this information is included in the narrative report of the History and Physical for every client moving forward. Beacon Point has also reviewed the History and Physical form which is currently utilized in order to implement additional sections to ensure regulatory information is captured for every client. Nursing Supervisor and Director of Compliance will perform routine audits to ensure needed information is present in all charts. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of patient records, the facility failed to ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment in four or four applicable patient records reviewed.
In each applicable female patient record reviewed, there was no documentation that the facility informed the patient of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has reviewed this regulation and is working with our Compliance & Licensing department to revise the existing consent to account for female clients being informed of possible risk to them or their unborn child from continued use of illicit drugs which will be available in facility EMR by June 1, 2024.
Medical staff will be educated on revised consent during upcoming quarterly department meeting (June 2024) and BPR Director of Compliance will ensure integration of the form during the admission process immediately following. BPR Lead Nurses and BPR Director of Compliance will conduct routine chart audits to ensure form is being completed. Any feedback or trends pertaining to the form will be discussed during quarterly QA meetings. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for maintenance or detoxification treatment in eight of eight applicable patient records reviewed.
Patient # 8 was admitted to the inpatient non-hospital activity on April 23, 2024 and was still active at the time of the inspection. There was no documentation of an informed, voluntary, written consent before an agent was administered in the patient record.
Patient # 9 was admitted to the inpatient non-hospital activity on December 11, 2023 and was discharged on December 18, 2023. There was no documentation of an informed, voluntary, written consent before an agent was administered in the patient record.
Patient # 10 was admitted to the inpatient non-hospital activity on March 10, 2024 and was discharged on March 18, 2024. The informed, voluntary, written consent in the patient record was missing all required components.
Patient # 11 was admitted to the inpatient non-hospital activity on December 3, 2024 and was discharged on December 7, 2023. There was no documentation of an informed, voluntary, written consent before an agent was administered in the patient record.
Patient # 12 was admitted to the inpatient non-hospital activity on December 15, 2023 and was discharged on December 19, 2023. There was no documentation of an informed, voluntary, written consent before an agent was administered in the patient record.
Patient # 13 was admitted to the inpatient non-hospital activity on December 28, 2023 and was discharged on December 30, 2023. There was no documentation of an informed, voluntary, written consent before an agent was administered in the patient record.
Patient # 14 was admitted to the inpatient non-hospital activity on January 6, 2024 and was discharged on January 10, 2024. There was no documentation of an informed, voluntary, written consent before an agent was administered in the patient record.
Patient # 26 was admitted to the inpatient non-hospital detoxification activity on November 10, 2023 and was discharged on November 14, 2023. There was no documentation of an informed, voluntary, written consent before an agent was administered in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point is working with our corporate Compliance & Licensing department to ensure the consent being utilized is in line with all applicable points within the regulation. All admissions moving forward will be educated on all available MAT options and will sign all applicable consents acknowledging such. BPR Director of Compliance and Facility Admissions Director will conduct routine chart audits to ensure documentation is being completed. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician determined the proper dosage level for a patient in two of eight applicable patient records reviewed.
Patient # 8 was admitted to the inpatient non-hospital activity on April 23, 2024 and was still active at the time of the inspection. The initial methadone dose was determined and ordered by a physician assistant, not a narcotic treatment physician. Additionally, there was no countersignature on the orders by a narcotic treatment physician.
Patient # 26 was admitted to the inpatient non-hospital detoxification activity on November 10, 2023 and was discharged on November 14, 2023. The initial methadone dose was determined and ordered by a physician assistant, not a narcotic treatment physician. Additionally, there was no countersignature on the orders by a narcotic treatment physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has re-educated our Medical provider to ensure all orders and dosing is reviewed by the Medical Director prior to implementation. Nursing Supervisor will perform routine reviews of charts to ensure co-signature present on orders, when applicable. |
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.
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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 notifying the emergency contact no later than 12 hours after a client is discharged from the facility against medical advice was submitted and approved by the Department for the November 8, 2023 and May 17, 2023, licensing inspections. Failing to notify the emergency contact no later than 12 hours after a client is discharged from the facility against medical advice was again found to be a deficiency in the May 1, 2024, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has implemented a process where all abnormal discharges are audited in real time by our "Abnormal Discharge Team" consisting of (5) staff members which helps to ensure all appropriate notifications to external individuals are made in a timely fashion, if valid consents are present in the client's chart, as well as all necessary information is documented appropriately within the client's chart.
Beacon Point will work to re-educate all staff on the importance of this notification being made within (12) hours of the discharge, per the licensing alert, during the upcoming department meetings scheduled in June 2024.
BPR Director of Compliance and BPR Clinical Director conduct weekly audits of Abnormal Discharges to ensure the Abnormal Discharge team has successfully obtained all required information, including EC notification per the Licensing Alert. |