INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 23-34, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Beyond Addiction Recovery and Treatment was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on April 23, 2025, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
A video camera, with audio capabilities was observed in a room that is sometimes utilized for small group sessions.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
Chief Operating Officer removed the camera from the library/group room. COO will be designated to ensure privacy for all clients, and that cameras are not located in counseling area.
Chief of Staff Development will be charged to ensure all compliance with DDAP regulations regarding privacy for clients is achieved moving forward. CEO will perform monthly physical plant walk throughs, as well, to ensure compliance with DDAP. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
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Observations
Based on a review of client records and the Confidentiality policy, the facility failed to ensure the disclosure of client-orientated information was limited to the project staff identified in its policy. The Administrator/Chief of Staff Development had access to client records. This job title was not identified as having access to client records in the Confidentiality policy.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
o Action Taken:
The CEO has revised the Confidentiality Policy to explicitly identify all relevant staff positions and titles. Each position is now assigned a defined level of access to confidential information based on job function and necessity. Administrator was promoted to Chief of Staff Development in the middle of DDAP documentation submission and on-site visit. Chief of Staff Development has full access to EHR as a part of the C-Suite Executive Team.
2. Assignment of Regulatory Oversight
o Action Taken:
The CEO and CCO have been formally designated as the responsible individuals for maintaining policy and procedural documents in accordance with current federal, state, and industry regulations.
o Ongoing Task:
Ensure real-time updates are made to documentation following regulatory or organizational changes.
o Responsible Party: CEO and CCO
3. Quarterly Policy Audits
o Action Planned:
The CEO and CCO will conduct quarterly audits of all organizational policies and procedures to verify:
Compliance with applicable laws and regulations
Alignment with internal Beyond Addiction protocols and standards
o Audit Schedule:
The first audit will occur within 90 days of this plan's implementation, with subsequent audits conducted quarterly.
o Responsible Party: CEO and CCO
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Monitoring and Evaluation:
The C-Suite Executives will receive quarterly compliance summaries to ensure accountability and sustained adherence to this correction plan.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the Client Rights inside the Client Handbook, the facility failed to ensure acknowledgement by clients that they have been notified of the right to not be discriminated in the provision of services on the basis of marital status.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
CEO amended the Client Handbook to ensure the right to not be discriminated in the provision of services on the basis of marital status was included. CEO and CCO will be tasked with keeping documents up to date with regulations. CEO and CCO will perform quarterly audits of the handbook s to ensure they are compliant with regulations and compliant with Beyond Addiction procedures. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of the Medication Dispensing and Administration policy, along with staff and client interviews, the facility failed to administer medication by individuals permitted to administer by Pennsylvania law.
The Medication Dispensing and Administration policy indicates only licensed medical professionals are authorized to dispense medications. During interviews, it was learned non-medical support staff are administering medications.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
Effective immediately, the facility will ensure that only trained and licensed medical personnel (e.g., LPNs, RNs, or certified medication aides where permitted by law) administer all medications to residents. Non-medical support staff will be strictly prohibited from preparing, handling, or administering any medications under any circumstance.
A full audit of current medication administration practices has been initiated.
All affected staff have been removed from any medication-related duties.
Medication will be properly stored for clients, but they will administer their medication to themselves according prescription instructions and observed by non-medical staff is medical staff is not present.
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2. How the Facility Will Ensure the Deficiency Does Not Recur
A revised Medication Administration Policy and Procedure Manual will be issued by 5/20/2025 and reviewed with all staff.
Mandatory in-service training will be provided to all staff, with separate sessions for:
Licensed medical staff (proper medication administration and documentation)
Non-medical support staff (clarification of role boundaries and reporting protocols)
A Medication Administration Oversight Log will be implemented to track who is administering medications on each shift.
The Director of Nursing (DON) or designee will conduct weekly audits for 8 weeks, then monthly for 3 months, to ensure compliance ? DON is hired and will start with Beyond Addiction on 5/8/2025
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3. Procedural Changes
Medication carts and secured storage areas will remain locked and accessible only to licensed or certified medical staff.
All med-pass shifts will be staffed exclusively with appropriately credentialed personnel.
Any staff member found violating this policy will be subject to disciplinary action up to and including termination.
The administrator and clinical leadership team will conduct random observations to verify compliance.
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4. Monitoring and Quality Assurance
This corrective action will be monitored through the facility's Quality Assurance and Performance Improvement (QAPI) program.
Results of audits and any deviations will be reported in monthly QAPI meetings.
Corrective action effectiveness will be reviewed quarterly, and additional training or policy adjustments will be made as needed.
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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 provide a complete client record, which is to include a discharge summary.
Client #5 was admitted on December 16, 2024, and was discharged on February 14, 2025. There was no documentation in the client record that a discharge summary had been completed.
This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
# **Updated Policy and Procedure: Timely Completion of Discharge Summaries**
## **1. Policy and Procedure Updates**
### **Documentation Timeline**
* All clinical documentation, including Discharge Summaries, must be entered into the Electronic Health Record (EHR) system **within 24 hours** of the patient encounter or discharge.
### **Late Documentation and Deficiency Correction**
* Any Discharge Summary not completed within the 24-hour timeframe must be:
* **Accompanied by a written justification** submitted to the Clinical Supervisor.
* **Reviewed and approved by a supervisor** before being finalized in the EHR.
* For the **specific chart identified in the deficiency**
* The assigned clinician has completed the Discharge Summary.
* The late entry has been reviewed and approved by the supervisor.
* A corrective note has been appended to the patient chart, acknowledging the deficiency and the resolution.
* The clinician has completed a **remedial training session** on documentation timeliness.
### **Audit and Compliance**
* Supervisors will perform **weekly documentation audits** to monitor adherence.
* Findings from these audits, including any late documentation and justifications, will be:
* Documented in **weekly audit logs**.
* Reviewed during **monthly staff meetings**.
* A **Plan of Correction** will be developed for repeated issues, including targeted training or additional oversight.
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## **2. Staff Training and Education**
### **Mandatory Training**
* All clinical staff must complete training on:
* DDAP documentation compliance standards.
* Clinical and operational impact of timely Discharge Summary documentation.
* Effective and efficient use of the EHR system.
### **Training Schedule**
* Initial policy implementation training will occur **within the first week** of rollout.
* **Quarterly refresher courses** are mandatory for all clinical staff.
* Remedial training will be required for staff identified through audits as having documentation deficiencies.
### **Documentation Best Practices**
* Training will emphasize:
* Avoiding excessive shorthand to maintain legibility.
* Immediate or same-day documentation after patient encounters for accuracy.
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## **3. Integration of Technology**
### **EHR Optimization**
The EHR system will be configured to:
* **Send automated reminders** for pending Discharge Summaries.
* **Flag overdue notes** in real-time for supervisor visibility.
* **Track justification submissions** for late entries.
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## **4. Monitoring and Accountability**
### **Documentation Audits**
* Random and scheduled audits will assess:
* Completion timelines of Discharge Summaries.
* Documentation accuracy and standards compliance.
* Patterns of delay by individual or team.
### **Performance Reviews**
* Documentation timeliness will be incorporated into **annual performance evaluations**.
* Ongoing or uncorrected delays may result in **progressive disciplinary action**.
### **Feedback and Remediation**
* Clinicians will receive **individualized feedback** after each audit.
* Staff requiring improvement will be scheduled for **additional training** or peer mentoring.
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## **5. Continuous Improvement**
### **Staff Feedback**
* Biannual surveys will gather staff input on barriers to timely documentation.
* Suggestions will be reviewed and used to update training and processes.
### **Process Refinement**
* Audit and feedback data will inform updates to documentation procedures.
* Leadership will adjust protocols and implement system or workflow changes as needed.
### **Ongoing Education**
* The organization will stay current on best practices and implement:
* Emerging EHR enhancements.
* State and federal regulatory changes.
* Staff development opportunities.
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## **Responsible Parties**
* **Clinical Supervisor**
* Enforce documentation policies.
* Conduct weekly audits and review justifications for late entries.
* Ensure resolution of cited deficiencies, including specific chart corrections.
* **Chief of Staff Development**
* Coordinate and track all training activities.
* Ensure timely completion of mandatory and remedial training.
* Evaluate training effectiveness and adjust materials accordingly.
* **IT Department**
* Maintain EHR system configurations.
* Support reminder functionality and overdue note tracking.
* Monitor system issues that may affect timely documentation.
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## **Supporting Documentation**
* Updated **Documentation of Discharge Summary Policy**
* **Corrective Action Record** for cited deficient chart
* **Audit Reports** (weekly logs and summaries)
* **Training Materials**, attendance records, and remedial training logs
* **Staff Feedback Surveys** and process improvement notes
* **Performance Evaluation Criteria** including documentation standards
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