INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 2021 through May 25, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ambrosia of Philadelphia 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide a counselor assistant with a written semiannual performance evaluation based upon measurable performance standards.
Employee #12 was hired as a counselor assistant on January 27, 2020. There was no written semiannual performance evaluation documented in the personnel record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point Clinical Leadership staff have been re-educated on the requirements for Counselor Assist. A performance review has been completed for our Counselor Assist, dated June 9, 2021 with a full review of current status and projection of transitioning timeline. Moving forward, all Counselor Assists will receive semi-annual performance reviews which will include a full review of their training plans so the individual is aware of the expectations during employment. The applicable policy has been updated to reflect this information effective June 11, 2021. |
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 twelve personnel records, the facility failed to document a current 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 every personnel record reviewed.
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 distributed Training Plans to all active employees. The employees have been asked to give an assessment on year 2020 as well as trainings they are interested in completing this calendar year. All active employees, except those 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 completed and on file no later than June 30, 2021. |
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 that 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 three of five applicable personnel records reviewed.
Employee # 1 was hired as the project director on March 1, 2019 and was due to have HIV/AIDS training and TB/STD training no later than March 1, 2021. The HIV/AIDS and TB/STD trainings were not completed until May 11, 2021.
Employee # 11 was hired as a counselor on February 17, 2020 and was due to have HIV/AIDS training and TB/STD training no later than February 17, 2021. The HIV/AIDS and TB/STD trainings were not completed until May 10, 2021.
Employee # 12 was hired as a counselor assistant on January 27, 2020 and was due to have HIV/AIDS training and TB/STD training no later than January 27, 2021. The HIV/AIDS training was not completed until May 18, 2021 and TB/STD training was not completed until April 26, 2021.
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 regulations with Human Resources and an ongoing training schedule has been created to ensure Communicable Disease Training is available to all incoming staff at least twice per quarter. It has been confirmed all active employees (hired prior to June 1, 2021) have Communicable Disease Training completed. |
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 project director and facility director completed at least 12 clock hours of training annually during the facility's January 1, 2020 through December 31, 2020 training year in two of two applicable personnel records reviewed.
Employee # 1 was hired as the project director on March 1, 2019. The personnel record documented 0 hours of training received during the 2020 training year.
Employee # 2 was hired as the facility director on November 25, 2019. The personnel record documented 0 hours of training received during the 2020 training year.
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 regulations with both the Project Director as well as the Facility Director (signed 6/2/21) and had them complete a Training Plan which details how they plan to obtain the required number of hours prior to the end of this calendar year. COVID-19 made it difficult for all staff to complete trainings as required as there were not many virtual options available and all in-person trainings had been cancelled. Provisions have been put into place to avoid this being an issue moving forward. |
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, 2020 through December 31, 2020 training year in one of one applicable personnel records reviewed.
Employee # 4 was hired as a clinical supervisor on October 21, 2019. The personnel record documented 2 hours of training received during the 2020 training year.
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 Supervisor and had them complete a Training Plan (signed 6/2/21) which details how they plan to obtain the required number of hours prior to the end of this calendar year. COVID-19 made it difficult for all staff to complete trainings as required as there were not many virtual options available and all in-person trainings had been cancelled. Provisions have been put into place to avoid this being an issue moving forward. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's May 2020 through April 2021 fire drill log, the facility failed to ensure that a fire alarm or a smoke detector was set off during the fire drills conducted in June 2020, September 2020, and January 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point conducted Emergency Preparedness drills during the months of June 2020, September 2020, and January 2020 which resulted in our alarm and detectors not being activated but rather an internal code be paged. Beacon Point is requesting an exception be granted for those months, submitted to DDAP on 6/22/2021. Moving forward, Beacon Point will create a plan to complete one Emergency Preparedness drill per quarter, requesting such exception from DDAP in advance. In the event this exception request is not granted, an additional Fire Drill will be conducted during those months to ensure the entire system is triggered and working appropriately. |
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 four of six applicable personnel records.
Employee # 1 was hired as the project director on March 1, 2019. There was no annual performance evaluation documented in the personnel record at the time of the inspection.
Employee # 2 was hired as the facility director on November 25, 2019. There was no annual performance evaluation documented in the personnel record at the time of the inspection.
Employee # 4 was hired as a clinical supervisor on October 21, 2019. There was no annual performance evaluation documented in the personnel record at the time of the inspection.
Employee #12 was hired as a counselor assistant on January 27, 2020. There was no annual performance evaluation documented in the personnel record at the time of the 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 met with our Leadership team and re-educated them on the Annual Performance Evaluation expectation. Evaluations for those employees reviewed during our on-site inspection are due to be completed no later than June 30, 2021 as well as any other outstanding Performance Evaluation. Moving forward, Beacon Point's Human Resources Specialist will send monthly reminders pertaining to upcoming Performance Evaluations due and any outstanding evaluations will be discussed during the quarterly Quality Assurance meetings held with Leadership. |
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.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, including the reason for termination in one of one applicable client records reviewed.
Client # 12 was admitted on April 15, 2021 and was administratively discharged on May 18, 2021. There was no documentation in the client 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.
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Plan of Correction
Effective June 1, 2021, Beacon Point's Leadership team has reviewed and approved an "Administrative Discharge Notice" which documents the reasons an individual can be Administratively Discharged from treatment as well as the appeal process available. Clients sign this form, are provided a copy, the form is then co-signed by the Leadership member who assisted with the discharge and it is uploaded to the clinical chart. Beacon Point's Leadership team has reviewed this form with all clinical staff to ensure global awareness. The Administrative Discharge process has been updated to include the issuance of this form in every instance, hard copies of which are maintained by the Director of Compliance. Beacon Point requires a member of our Leadership team be involved in all decisions to Administratively Discharge a client in order to ensure this notification is given in every instance. All Administrative Discharge notices will be reviewed during the quarterly Quality Assurance meeting to identify trends and to identify any facility improvements necessary. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.
Client # 12 was admitted on April 15, 2021 and was administratively discharged on May 18, 2021. There was no documentation in the client record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective June 1, 2021, Beacon Point's Leadership team has reviewed and approved an "Administrative Discharge Notice" which documents the reasons an individual can be Administratively Discharged from treatment as well as the appeal process available. Clients sign this form, are provided a copy, the form is then co-signed by the Leadership member who assisted with the discharge and it is uploaded to the clinical chart.
Verbiage included on the form is as follows:
"You have the right to appeal this decision, in writing within (48) hours of your discharge, stating the objection and also identifying the reason why the decision made should be reviewed. Beacon Point's Director of Compliance will review the grievance and/or request for appeal and make a determination of what actions should be taken in the best interest of the client within (7) business days from the date the appeal request is received.
If you disagree with the Director of Compliance's decision, an appeal may be made to Beacon Point's Facility Director who will make a determination of what actions should be taken in the best interest of the client within (7) business days from the date the next level appeal request is received."
The Administrative Discharge process has been updated to include the issuance of this form in every instance, hard copies of which are maintained by the Director of Compliance. Beacon Point requires a member of our Leadership team be involved in all decisions to Administratively Discharge a client in order to ensure this notification is given in every instance. All Administrative Discharge notices will be reviewed during the quarterly Quality Assurance meeting to identify trends and to identify any facility improvements necessary. Any appeals received will also be reviewed at this time along with the decision rendered. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility failed to verify the individual's identity, which is to include an emergency contact, prior to the administration of an agent in two of seven applicable patient records reviewed.
Patient # 4 was admitted to the inpatient detoxification activity on May 17, 2021 and was discharged on May 21, 2021. There was no documentation, in the patient record, of an emergency contact prior to the administration of an agent.
Patient # 11 was admitted to the inpatient residential treatment and rehabilitation activity on May 22, 2021 and was discharged on May 25, 2021. There was no documentation, in the patient record, of an emergency contact prior to the administration of an agent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point, effective June 1, 2021, has put additional provisions in place to obtain Emergency Contact information from all incoming admissions, which includes utilizing Motivational Interviewing as well as collateral contact information from Insurance Providers. Due to the increase in our homeless population, Beacon Point is collaborating with community-based resources in order to explore additional ongoing support for our clients who do not otherwise have an emergency contact available. All emergency contacts are added to the digital clinical chart on the client's information page and/or "face-sheet." In all instances where an emergency contact is obtained, there is an auto-generated consent the client is requested to sign which is also maintained in the EMR. Compliance Officer will conduct bi-weekly chart audits to ensure improvement is made in this area until facility reaches 100% compliance. Compliance percentage and ongoing plan for improvement will be discussed during quarterly Quality Assurance 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 seven applicable patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in every applicable patient records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point Medical Team has added verbiage to our "Subutex/Suboxone Patient Information" form (as we do not currently administer MMT) signed by all incoming admissions which includes the notification of alternative medication methods as well as possible risks and complications while taking the medication. These changes are effective June 1, 2021 and will populate automatically to all forms after this date.
Beacon Point's EMR generates the updated form for every new admission which is reviewed during the nursing assessment portion of the admission process, effective 6/1/2021.
Compliance Officer will conduct bi-weekly chart audits to ensure form is populated for every new admission after 6/1/21 and to confirm nursing team is adding form to clinical charts as required. Any deficits noted will be reviewed at quarterly Quality Assurance meetings until 100% compliance is achieved. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of three applicable client records reviewed.
Client # 8 was admitted on May 10, 2021 and was still active at the time of the inspection. The individual treatment plan was completed on May 19, 2021 but the plan did not document the frequency of treatment and rehabilitation services.
Client # 12 was admitted on April 15, 2021 and was discharged on May 18, 2021. The individual treatment plan was completed on April 16, 2020 but the plan did not document the type of treatment and rehabilitation services.
Client # 13 was admitted on March 30, 2021 and was discharged on April 19, 2021. The individual treatment plan was completed on March 31, 2021 but the plan did not document the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has scheduled an additional training for all clinical staff, to be held on June 23, 2021, where they will be re-educated on the creation of client-centered treatment plans as well as the applicable regulatory guidelines. Effective June 24, 2021, Director of Compliance and Compliance Officer will begin conducting weekly audits of Treatment Plans to ensure required information is present. Audit results will be reviewed with Clinical Leadership during quarterly Quality Assurance meetings. Since the clients reviewed during the on-site inspection have since discharged, Beacon Point is unable to alter the treatment plans pertaining to those individuals. |
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 discharge summary, in the client' complete record, in two of four applicable client records reviewed.
Client # 13 was admitted on March 30, 2021 and was discharged on April 19, 2021. The client record did not document a discharge summary at the time of the inspection.
Client #14 was admitted on April 14, 2021 and was discharged on April 22, 2021. The client record did not document a discharge summary at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has updated both clinical charts reviewed with the required Discharge Summary (effective and timestamped 6/22/2021). Clinical staff have been reminded all summaries are due to be in the chart within (10) days of the client's date of discharge. Internal audits will be conducted by Compliance officer weekly to ensure ongoing compliance with this regulation. |