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 22, 2025 through April 25, 2025 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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704.11(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 at least 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 within the regulatory time frame in thirteen of thirty-two applicable personnel records reviewed.
Employee # 11 was hired as a counselor on March 25, 2024. The tuberculosis, sexually transmitted diseases, and other health related topics training was due no later than March 25, 2025; however, the training was not completed as of the date of the inspection.
Employee # 21 was hired as a BHT on September 6, 2022. The tuberculosis, sexually transmitted diseases, and other health related topics training was due no later than September 6, 2024; however, the training was not completed as of the date of the inspection.
Employee # 22 was hired as a BHT on March 28, 2023. The tuberculosis, sexually transmitted diseases, and other health related topics training was due no later than March 28, 2025; however, the training was not completed as of the date of the inspection.
Employee # 23 was hired as a BHT on February 27, 2023. The HIV/AIDS training and the tuberculosis, sexually transmitted diseases, and other health related topics training were due no later than February 27, 2025; however, both trainings were not completed as of the date of the inspection.
Employee # 24 was hired as a BHT on April 17, 2023. The HIV/AIDS training and the tuberculosis, sexually transmitted diseases, and other health related topics training were due no later than April 17, 2025; however, both trainings were not completed as of the date of the inspection.
Employee # 25 was hired as a BHT on November 3, 2021. The HIV/AIDS training and the tuberculosis, sexually transmitted diseases, and other health related topics training were due no later than November 3, 2023; however, both trainings were not completed as of the date of the inspection.
Employee # 26 was hired as a BHT on August 8, 2022. The tuberculosis, sexually transmitted diseases, and other health related topics training was due no later than August 8, 2024; however, the training was not completed as of the date of the inspection.
Employee # 27 was hired as a BHT on January 16, 2023. The tuberculosis, sexually transmitted diseases, and other health related topics training was due no later than January 16, 2025; however, the training was not completed as of the date of the inspection.
Employee # 28 was hired as a Lead BHT on January 3, 2020. The tuberculosis, sexually transmitted diseases, and other health related topics training was due no later than January 3, 2022; however, the training was not completed as of the date of the inspection.
Employee # 29 was hired as a BHT on April 7, 2022. The HIV/AIDS training and the tuberculosis, sexually transmitted diseases, and other health related topics training were due no later than April 7, 2024; however, both trainings were not completed as of the date of the inspection.
Employee # 30 was hired as a BHT on May 23, 2022. The HIV/AIDS training and the tuberculosis, sexually transmitted diseases, and other health related topics training were due no later than May 3, 2024; however, both trainings were not completed as of the date of the inspection.
Employee # 31 was hired as a BHT on December 30, 2021. The tuberculosis, sexually transmitted diseases, and other health related topics training was due no later than December 30, 2023; however, the training was not completed as of the date of the inspection.
Employee # 32 was hired as a Lead BHT on November 14, 2022. The tuberculosis, sexually transmitted diseases, and other health related topics training was due no later than November 14. 2024; however, the training was not completed as of the date of the inspection.
This is a repeat citation from the May 1, 2024 annual licensing renewal inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Beacon Point is currently working with our training provider, MedTrainer, to provide these trainings to all employees, making the curriculum available for review at our next 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.
All employees will be required to complete the identified training by August 1, 2025. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the facility clean, safe, sanitary, and in good repair at all times for the safety and well-being of residents, employees, and visitors.
At the time of the physical plant inspection, conducted on April 24, 2025 at approximately 1:30pm, there was a large hole in the middle of the floor in bedroom 613, which had created a tripping hazard.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's Director of Operations has collaborated with the Property Manager to have the hole repaired on 4/26/2025.
All client rooms will be monitored on a weekly basis moving forward to ensure any additional repairs are addressed in a timely fashion. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
At the time of the inspection, conducted on April 24, 2025 at approximately 1:30pm, there were no operable soap dispensers in any of the bathrooms located in rooms 404, 407, 409, 507, 512, 602, 610, and 709. Additionally, there were missing or broken paper towel dispensers in the bathrooms located in rooms 409, 507, 610, and 702.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's Director of Operations has collaborated with our supply vendor to have new soap dispensers delivered on 5/24/2025 and all noted dispensers have been replaced. Facility is conducting weekly, documented, walk-through inspections of each client bedroom to ensure all repairs are addressed in real-time. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
At the time of the inspection, conducted on April 24, 2025 at approximately 1:30pm, there was a broken toilet that did not flush located in the bathroom in room 712.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's Director of Operations has implemented weekly, documented, walk-through inspections of each client bedroom to ensure all repairs are addressed in real-time. The toilet in room 712 was repaired on 4/25/2025. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed.
At the time of the inspection, conducted on April 24, 2025 at approximately 1:30pm, there was a portable space heater located in the counselor's office in 721B.
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 spoken with the staff member who occupies the office this item was found in and re-educated them on the applicable regulations. The space heater was removed on the day of our physical plant inspection (4/24/2025). All staff have been educated via respective department meetings on the regulations and prohibited items. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection, the facility failed to limit smoking to designated areas.
At the time of the inspection, conducted on April 24, 2025 at approximately 1:30pm, there was a strong cigarette smoke smell emanating from the bathrooms in client rooms 409 and 512.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's Director of Operations has implemented weekly, documented, walk-through inspections of all client areas to ensure client areas are kept clean at all times. |
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 the fire extinguishers upon staff employment in thirteen of fourteen applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on October 26, 2023. There was documentation in the personnel record indicating the fire extinguisher training was completed; however, there was no date on the training certificate to verify if the training was completed upon staff employment.
Employee # 4 was hired as a clinical supervisor on July 29, 2024. There was documentation in the personnel record indicating the fire extinguisher training was not completed until January 27, 2025.
Employee # 5 was hired as a counselor on January 28, 2025. There was no documentation in the personnel record indicating the fire extinguisher training was completed as of the date of the inspection.
Employee # 6 was hired as a counselor on February 10, 2025. There was documentation in the personnel record indicating the fire extinguisher training was not completed until February 21, 2025.
Employee # 7 was hired as a counselor on December 11, 2024. There was documentation in the personnel record indicating the fire extinguisher training was not completed until January 7, 2025.
Employee # 8 was hired as a counselor on August 14, 2024. There was documentation in the personnel record indicating the fire extinguisher training was completed; however, there was no date on the training certificate to verify if the training was completed upon staff employment.
Employee # 10 was hired as a counselor on April 15, 2025. There was no documentation in the personnel record indicating the fire extinguisher training was completed as of the date of the inspection.
Employee # 15 was hired as a counselor assistant on December 11, 2024. There was documentation in the personnel record indicating the fire extinguisher training was not completed until January 8, 2025.
Employee # 16 was hired as a counselor assistant on December 3, 2024. There was documentation in the personnel record indicating the fire extinguisher training was not completed until January 16, 2025.
Employee # 17 was hired as a counselor assistant on October 16, 2024. There was documentation in the personnel record indicating the fire extinguisher training was not completed until January 8, 2025.
Employee # 18 was hired as a counselor on December 2, 2024. There was documentation in the personnel record indicating the fire extinguisher training was completed; however, there was no date on the training certificate to verify if the training was completed upon staff employment.
Employee # 19 was hired as a counselor assistant on September 3, 2024. There was no documentation in the personnel record indicating the fire extinguisher training was completed as of the date of the inspection.
Employee # 20 was hired as a counselor on June 25, 2024. There was documentation in the personnel record indicating the fire extinguisher training was completed; however, there was no date on the training certificate to verify if the training was completed upon staff employment.
This is a repeat citation from the May 1, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's People Operations department is actively reviewing all applicable state and regulatory training requirements to ensure our internal training offerings are fully compliant. This includes ensuring proper documentation, appropriate course selection, and adherence to timelines outlined by DDAP and the Pennsylvania Department of Health.
Beacon Point's corporate Director of Compliance and Licensing has communicated directly with our training provider, MedTrainer, to ensure that all required modules are properly bundled and labeled according to DDAP standards. The provider has confirmed the ability to produce certificates that include clearly marked completion dates and course content to meet licensing requirements.
All employees identified during the licensing inspection whose training certificates were deemed insufficient due to missing dates or incomplete documentation will be required to re-take the appropriate trainings using updated, compliant materials.
These trainings will be completed and fully documented no later than August 1, 2025, which serves as both the training remediation deadline and the corrective action completion date. |
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 all personnel, on all shifts, were trained to perform assigned tasks during emergencies in thirteen of fourteen applicable personnel records reviewed.
Employee # 1 was hired as the project director and facility director on October 26, 2023. There was documentation in the personnel record indicating the emergency preparedness training was completed; however, there was no date on the training certificate to verify when the training as completed.
Employee # 4 was hired as a clinical supervisor on July 29, 2024. There was documentation in the personnel record indicating the emergency preparedness training was not completed until
January 27, 2025.
Employee # 5 was hired as a counselor on January 28, 2025. There was no documentation in the personnel record indicating the emergency preparedness training was completed as of the date of the inspection.
Employee # 6 was hired as a counselor on February 10, 2025. There was documentation in the personnel record indicating the emergency preparedness training was not completed until
February 21, 2025.
Employee # 7 was hired as a counselor on December 11, 2024. There was documentation in the personnel record indicating the emergency preparedness training was not completed until
January 7, 2025.
Employee # 8 was hired as a counselor on August 14, 2024. There was documentation in the personnel record indicating the emergency preparedness training was completed; however, there was no date on the training certificate to verify when the training as completed.
Employee # 10 was hired as a counselor on April 15, 2025. There was no documentation in the personnel record indicating the emergency preparedness training was completed as of the date of the inspection.
Employee # 15 was hired as a counselor assistant on December 11, 2024. There was documentation in the personnel record indicating the emergency preparedness training was not completed until January 8, 2025.
Employee # 16 was hired as a counselor assistant on December 3, 2024. There was documentation in the personnel record indicating the emergency preparedness training was not completed until January 16, 2025.
Employee # 17 was hired as a counselor assistant on October 16, 2024. There was documentation in the personnel record indicating the emergency preparedness training was not completed until January 8, 2025.
Employee # 18 was hired as a counselor on December 2, 2024. There was documentation in the personnel record indicating the emergency preparedness training was completed; however, there was no date on the training certificate to verify when the training as completed.
Employee # 19 was hired as a counselor assistant on September 3, 2024. There was no documentation in the personnel record indicating the emergency preparedness training was completed as of the date of the inspection.
Employee # 20 was hired as a counselor on June 25, 2024. There was documentation in the personnel record indicating the emergency preparedness training was completed; however, there was no date on the training certificate to verify when the training as completed.
This is a repeat citation from the May 1, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's People Operations department is actively reviewing the applicable training regulations to ensure that all offerings meet or exceed the requirements outlined by the Department of Drug and Alcohol Programs (DDAP) and the Pennsylvania Department of Health.
The corporate Director of Compliance and Licensing has communicated directly with our training vendor, MedTrainer, to identify and implement bundled training modules that meet DDAP standards. These updated training modules include all required elements, including proper labeling, content alignment, and certificates that clearly reflect the date of completion.
Employees whose certificates were previously found to be insufficient due to missing or unclear completion dates have been identified. These employees are required to re-take the appropriate trainings using the revised and compliant modules. Training assignments have already been issued.
All re-training will be completed and properly documented no later than August 1, 2025, ensuring full compliance with documentation standards at the time of reinspection. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for the completion of an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities, for the project's fiscal year ending December 31, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has worked with our independent accounting firm to tighten deadlines and re-establish expectations to ensure there is an audit available at all licensing inspections moving forward. Fiscal accounting will be made available to Beacon Point staff for the applicable audit year by the end of the first quarter annually to ensure results are available at time of licensing inspections. |
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 the facility's decision to involuntarily terminate the client's treatment at the project in two of four applicable client records reviewed.
Client # 11 was admitted to the inpatient non-hospital activity on May 3, 2024 and was involuntarily terminated on June 2, 2024. There was no documentation, in the record, indicating the client received written notice of the involuntary termination from the project.
Client # 14 was admitted to the inpatient non-hospital activity on February 23, 2025 and was involuntarily terminated on April 22, 2025. There was no documentation, in the record, indicating the client received written notice of the involuntary termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point Leadership has re-educated all staff via respective monthly department meetings on the importance of having this document completed whenever there is an Administrative Discharge and has re-implemented bi-weekly chart audits to ensure global compliance. |
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 the client an opportunity to request reconsideration of a decision terminating treatment in two of four applicable client records reviewed.
Client # 11 was admitted to the inpatient non-hospital activity on May 3, 2024 and was involuntarily terminated on June 2, 2024. There was no documentation, in the record, indicating the client was given an opportunity to request reconsideration of the involuntary termination from the project.
Client # 14 was admitted to the inpatient non-hospital activity on February 23, 2025 and was involuntarily terminated on April 22, 2025. There was no documentation, in the record, indicating the client was given an opportunity to request reconsideration of the involuntary termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point Leadership has re-educated all staff via respective monthly department meetings on the importance of having this document completed whenever there is an Administrative Discharge and has re-implemented bi-weekly chart audits to ensure global compliance. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
Based on an administrative review, the facility failed to follow their policies and procedures regarding the reporting mechanism to ensure that reporting of unusual incidents and ensuring the reporting is in compliance with State and Federal confidentiality laws.
The facility's unusual incident policy and procedure stated that "when appropriate, a report will be sent to DDAP via the department's online portal and subsequently submitted to all other appropriate stakeholders/governing bodies." At the time of the inspection, there was documentation indicating that only 1 out of 154 reportable incidents, since the previous licensing inspection, were reported to the Department.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has refined its internal reporting form to include additional information which when reviewed will ensure no reportable incidents are missed and all event reporting is done within the timeframes required. Bi-weekly audits have been implemented and will be completed by the Director of Compliance to ensure reporting is completed within the timeframes dictated. |
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 one of twelve applicable patient records reviewed.
Patient # 4 was admitted to the inpatient non-hospital detoxification activity on November 6, 2024 and was discharged on November 9, 2024. There was no documentation of an informed, voluntary, written consent before an agent was administered in the patient record at the time of the inspection.
This is a repeat citation from the May 1, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has implemented check-lists to ensure this consent is properly signed by all applicable clients. Check lists are audited by Nursing Supervisors on a bi-weekly basis and submitted to Director of Nursing for analysis of any trends or deficiencies which will be discussed during monthly Leadership meetings. |
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 one of twelve applicable patient records reviewed.
Patient # 7 was admitted to the inpatient non-hospital detoxification activity on October 15, 2024 and was discharged on October 19, 2024. On October 17, 2024, the initial methadone dose was determined and ordered by a physician assistant, not a narcotic treatment physician. Additionally, there was no physician countersignature on the determination and order of the initial methadone dosage.
This is a repeat citation from the May 1, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has reviewed this regulation with contracted Medical Provider team to ensure any and all orders are co-signed by an available and credentialed MD. Chart audits will be completed on a bi-weekly basis by Nursing Supervisors and deficiencies will be reported to Director of Nursing. These deficiencies and any identifiable trends will be discussed during monthly Leadership meetings in order to implement provisions to satisfy regulation requirement. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the date of the admission of the patient and the date of the initial dose given to the patient in six of six applicable patient records reviewed.
Patient # 1 was transferred in and admitted to the inpatient non-hospital detoxification activity on April 15, 2025 and was still active at the time of inspection. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient # 2 was transferred in and admitted to the inpatient non-hospital detoxification activity on March 26, 2025 and was still active at the time of inspection. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient # 5 was transferred in and admitted to the inpatient non-hospital detoxification activity on July 15, 2024 and was discharged on July 22, 2024. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient # 8 was transferred in and admitted to the inpatient non-hospital activity on April 11, 2025 and was active at the time of inspection. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient # 12 was transferred in and admitted to the inpatient non-hospital activity on July 18, 2024 and was discharged on September 3, 2024. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient # 13 was transferred in and admitted to the inpatient non-hospital activity on August 16, 2024 and was discharged on September 20 2024. The record did not include documentation that the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point's Director of Compliance and Facility Admissions Director have implemented a protocol to ensure proper notification is given to referring providers of a client's successful admission to BPR. This communication will be added to the client's chart via Progress Note and bi-weekly audits will be completed to ensure completion. Any deficiencies, barriers, or complications will be documented and reported to Leadership via monthly meetings and provisions can be put in place. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of patient records, the facility failed to notify the Department within 48 hours following complaints of patient abuse (physical, verbal, sexual and emotional) in three of three applicable patient records.
Patient # 4 was admitted to the inpatient non-hospital detoxification activity on November 6, 2024 and was administratively discharged on November 9, 2024 for an act of aggression/assault and the incident was not reported to the Department.
Patient # 6 was admitted to the inpatient non-hospital detoxification activity on August 4, 2024 and was administratively discharged on August 11, 2024 for an act of aggression/assault and the incident was not reported to the Department.
Patient # 14 was admitted to the inpatient non-hospital activity on February 23, 2025 and was administratively discharged on April 22, 2025 for an act of aggression/assault and the incident was not reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beacon Point has refined its internal reporting form to include additional information which when reviewed will ensure no reportable incidents are missed and all event reporting is done within the timeframes required. Bi-weekly audits have been implemented and will be completed by the Director of Compliance to ensure reporting is completed within the timeframes dictated.
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