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 7, 2026 through April 10, 2026 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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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on an administrative review, the facility failed to present the plan documenting the qualifications and training of staff to the Department licensing representatives at the time of the project's site visit.
Leading up to and during the inspection, the facility was unable to produce a complete Staffing Requirements Facility Summary Report, with accurate documentation of staff qualifications and trainings, after multiple requests and attempts to provide technical assistance by the Department licensing representative.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action Plan
Citation: 704.2(b) Staffing Plan
Deficiency: The facility failed to present a complete plan documenting staff qualifications and training at the time of the site visit. The facility was also unable to provide a complete and accurate Staffing Requirements Facility Summary Report during the inspection process.
Corrective Action
Beacon Point Recovery Center will develop and maintain a complete and up to date Staffing Requirements Facility Summary Report that includes all required staff qualifications, credentials, and training documentation. This report will be reviewed prior to any licensing visit and updated routinely to ensure it is accurate and readily available upon request.
Action Steps
A full review of all personnel files will be completed to verify staff qualifications, credentials, and required trainings.
Missing documentation will be identified and obtained for any staff file that is incomplete.
The Staffing Requirements Facility Summary Report will be updated to reflect accurate and current information for all applicable staff.
The completed report will be stored in a designated compliance binder and electronic folder so it can be immediately presented during future inspections.
The report will be reviewed on a routine basis to ensure it remains current.
Responsible Person
Executive Director
Director of Compliance
Human Resources
Completion Date
June 21, 2026
Monitoring Method
The Staffing Requirements Facility Summary Report will be reviewed monthly by leadership to confirm that all staff qualifications, licenses, certifications, and trainings are current and properly documented. Any missing items identified during review will be addressed immediately.
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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 files, the facility to ensure all individuals met the qualifications for the position of counselor in one of eight applicable personnel records reviewed.
Employee #14 was hired as a counselor on January 25, 2021 and was still in the position at the time of the inspection. The employee does not possess a qualifying degree with a major in chemical dependency, psychology, social work, counseling, nursing or a related field. The employee did qualify as a counselor with a CADC certification; however, the certification expired on February 11, 2026 and no other qualification documentation was provided.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Citation:
28 Pa. Code § 704.7(b) Counselor Qualifications
Deficiency:
Based on a review of personnel files, the facility failed to ensure all individuals met the qualifications for the position of counselor in one of eight applicable personnel records reviewed. Employee #14 was hired as a counselor on January 25, 2021 and remained in the position at the time of the inspection. The employee did not possess a qualifying degree in chemical dependency, psychology, social work, counseling, nursing, or a related field. The employee had qualified as a counselor through CADC certification; however, that certification expired on February 11, 2026, and no other qualifying documentation was provided.
Immediate correction:
The personnel file for Employee #14 will be reviewed immediately to determine whether updated CADC certification or other qualifying documentation is available. If current qualifying documentation cannot be produced, the employee will be removed from the counselor role until compliance is verified.
Corrective action steps:
Review Employee #14's personnel file in full for current qualification documentation.
Obtain and file updated certification or other qualifying documentation, if available.
If no qualifying documentation is available, remove the employee from the counselor position until the qualification requirement is met.
Conduct an audit of all counselor personnel files to verify that each counselor meets at least one of the regulatory qualification pathways.
Create and maintain a credential tracking log for all counselors and other licensed or certified staff, including expiration dates.
Implement routine leadership review of credentials to ensure renewals and supporting documentation are obtained before expiration.
Responsible person:
Executive Director
Human Resources
Director of Compliance
Completion date:
June 21, 2026
Monitoring method:
Personnel files for all counselors will be reviewed monthly to verify that qualifications, licenses, certifications, and supporting documentation are current and complete. The credential tracking log will be updated routinely, and any upcoming expiration dates will be addressed before lapse. Any employee who does not meet counselor qualification requirements will not be permitted to function in the counselor role until compliance is confirmed.
Evidence maintained:
Updated personnel file for Employee #14
Copies of current certifications, licenses, or qualifying documentation
Counselor personnel file audit tool
Credential tracking log
Monthly compliance review records |
704.8(a)(1) - (5) & (b) LICENSURE Qualification Level
704.8. Qualifications for the position of counselor assistant.
(1) A Master's Degree in a human service area.
(2) A Bachelor's Degree in a human service area.
(3) Licensure in this Commonwealth as a registered nurse.
(4) An Associate's Degree in a human service area.
(5) A high school diploma or General Education Development (GED) equivalent.
(b) A counselor assistant shall also complete the training requirements in 704.11 (relating to staff development program).
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Observations
Based on a review of personnel records, the facility failed to ensure that counselor assistants met the educational qualifications in one of four applicable personnel records reviewed.
Employee #15 was hired as a counselor assistant on October 6, 2025 and was still in the position at the time of the inspection. There was no documentation in the personnel record indicating the employee had a college degree, high school diploma, or a GED.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
28 Pa. Code § 704.8(a)(1) to (5) and (b) Counselor Assistant Qualifications
Deficiency:
Based on a review of personnel records, the facility failed to ensure that counselor assistants met the educational qualifications in one of four applicable personnel records reviewed. Employee #15 was hired as a counselor assistant on October 6, 2025 and remained in the position at the time of the inspection. There was no documentation in the personnel record indicating the employee had a college degree, high school diploma, or GED.
Immediate correction:
The personnel file for Employee #15 will be reviewed immediately to determine whether documentation of the employee's educational qualification is available and can be placed in the file. If the required documentation cannot be produced, the employee's status in the counselor assistant role will be reviewed until compliance is confirmed.
Corrective action steps:
Review Employee #15's personnel file in full for proof of educational qualification.
Obtain and place in the personnel file a copy of the employee's qualifying diploma, GED, or degree documentation.
If documentation cannot be obtained immediately, remove the employee from functioning in the counselor assistant role until the minimum qualification is verified.
Conduct an audit of all counselor assistant personnel files to ensure each file contains the required educational documentation.
Implement a personnel file checklist requiring verification of educational qualifications before an employee is cleared for the counselor assistant position.
Add routine leadership review of new hire files to confirm all minimum qualification documents are present and complete.
Responsible person:
Executive Director
Human Resources
Director of Compliance
Completion date:
June 21, 2026
Citation:Monitoring method:
All counselor assistant personnel files will be reviewed monthly to verify that required educational documentation is present and complete. New hire personnel files will be checked before final clearance into the role. Any employee lacking required qualification documentation will not be permitted to function in the counselor assistant position until compliance is verified.
Evidence maintained:
Updated personnel file for Employee #15
Copy of diploma, GED, or degree documentation
Counselor assistant personnel file audit tool
New hire file checklist
Monthly compliance review records |
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 ensure counselor assistants received a written semiannual performance evaluation, based upon measurable performance standards, in one of two applicable personnel records reviewed.
Employee #17 was hired as a counselor assistant on September 24, 2025. A semiannual performance evaluation was due no later than March 24, 2026; however, there was no documentation in the personnel record indicating the semiannual performance evaluation was completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Citation:
28 Pa. Code § 704.9(b) Performance Evaluation
Deficiency:
Based on a review of personnel records, the facility failed to ensure counselor assistants received a written semiannual performance evaluation, based upon measurable performance standards, in one of two applicable personnel records reviewed. Employee #17 was hired as a counselor assistant on September 24, 2025. A semiannual performance evaluation was due no later than March 24, 2026; however, there was no documentation in the personnel record indicating the semiannual performance evaluation was completed as of the date of the inspection.
Immediate correction:
The personnel file for Employee #17 will be reviewed immediately, and the required semiannual performance evaluation will be completed and placed in the file. The supervisor will ensure the evaluation is based on measurable performance standards and is properly dated and signed.
Corrective action steps:
Complete the overdue semiannual performance evaluation for Employee #17 and place it in the personnel file.
Review all counselor assistant personnel files to determine whether any other semiannual evaluations are due or missing.
Create a performance evaluation tracking log tied to hire dates and required evaluation due dates.
Implement a process requiring supervisors to complete and submit semiannual evaluations on or before the due date.
Review personnel file requirements with supervisors to ensure all evaluations are completed, signed, dated, and filed timely.
Add routine leadership review of evaluation compliance to confirm ongoing completion.
Responsible person:
Executive Director
Human Resources
Clinical Director
Completion date:
June 21, 2026
Monitoring method:
Counselor assistant personnel files will be reviewed monthly to verify that all required semiannual evaluations are completed on time and maintained in the file. The evaluation tracking log will be monitored routinely, and supervisors will be held responsible for timely completion of all required performance evaluations.
Evidence maintained:
Completed semiannual performance evaluation for Employee #17
Counselor assistant personnel file audit tool
Performance evaluation tracking log
Supervisor review records
Monthly compliance review records |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors or trained counselors were providing close supervision to a counselor assistant, who has a master's degree and counsels clients, for at least the first 3 months of the counselor assistant's employment in one of one applicable personnel record reviewed.
Employee #17 was hired as a counselor assistant on September 24, 2025 and was still in the position. The employee has a master's degree in a non-qualifying field; thus, they can counsel clients under close supervision for the first 3 months in the position. Close supervision is defined as formal documented case review and an additional hour of direct observation by a supervising counselor or clinical supervisor once a week. There was no documentation in the personnel record indicating the employee received direct observation once a week during the first 3 months of employment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Citation:
28 Pa. Code § 704.9(c) Supervised Period
Deficiency:
Based on a review of personnel records, the facility failed to ensure clinical supervisors or trained counselors were providing close supervision to a counselor assistant, who has a master's degree and counsels clients, for at least the first 3 months of employment in one of one applicable personnel record reviewed. Employee #17 was hired as a counselor assistant on September 24, 2025 and remained in the position at the time of the inspection. The employee has a master's degree in a non-qualifying field and was permitted to counsel clients under close supervision for the first 3 months in the position. Close supervision includes formal documented case review and an additional hour of direct observation by a supervising counselor or clinical supervisor once a week. There was no documentation in the personnel record showing the employee received direct observation once a week during the first 3 months of employment.
Immediate correction:
The personnel file for Employee #17 will be reviewed immediately to determine whether any supervision documentation can be retrieved and filed. Ongoing supervision requirements will be reviewed with the employee's supervisor, and current supervision documentation practices will be corrected at once.
Corrective action steps:
Review Employee #17's personnel file for any existing supervision records and place all available documentation in the file.
Review the supervision requirements for counselor assistants with clinical supervisors and trained counselors, including the requirement for formal documented case review and one hour of direct observation each week during the supervised period.
Implement a standardized supervision log for counselor assistants that includes date, type of supervision, case review, direct observation, and supervisor signature.
Audit all counselor assistant personnel files to ensure required supervision documentation is present for the applicable supervised period.
Require supervisors to complete and submit supervision documentation on an ongoing basis for all counselor assistants within their supervised period.
Add routine leadership review of counselor assistant supervision records to ensure continued compliance.
Responsible person:
Clinical Director
Clinical Supervisors
Director of Compliance
Completion date:
June 21, 2026
Monitoring method:
Counselor assistant supervision records will be reviewed monthly to verify that all required supervision, including direct observation and documented case review, is being completed and maintained in the personnel file during the applicable supervised period. Supervisors will be expected to submit documentation routinely, and any missing supervision records will be addressed immediately.
Evidence maintained:
Updated personnel file for Employee #17
Counselor assistant supervision logs
Personnel file audit tool
Supervisor training or review records
Monthly compliance review records |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure counselor assistants documented to the facility director that they are working towards counselor status, which is to be documented upon completion of each calendar year, in one of two applicable personnel records reviewed.
Employee #17 was hired as a counselor assistant on September 24, 2025. There was no documentation to the facility director, in the personnel record, documenting how they were working towards counselor status at the end of the 2025 calendar year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Citation:
28 Pa. Code § 704.10 Counselor Assistant Promotion
Deficiency:
Based on a review of personnel records, the facility failed to ensure counselor assistants documented to the facility director that they were working toward counselor status, which is required to be documented upon completion of each calendar year, in one of two applicable personnel records reviewed. Employee #17 was hired as a counselor assistant on September 24, 2025. There was no documentation in the personnel record to the facility director showing how the employee was working toward counselor status at the end of the 2025 calendar year.
Immediate correction:
The personnel file for Employee #17 will be reviewed immediately, and documentation will be obtained and placed in the file describing how the employee is working toward counselor status. This documentation will be submitted to the facility director and maintained in the personnel record.
Corrective action steps:
Review Employee #17's personnel file for any existing documentation related to progress toward counselor status and place all available records in the file.
Obtain a written statement for Employee #17 documenting how the employee is working toward counselor status and place it in the personnel file.
Review all counselor assistant personnel files to determine whether annual documentation of progress toward counselor status is present and complete.
Implement a standardized annual counselor assistant progress form to be completed at the end of each calendar year and submitted to the facility director.
Educate supervisors and counselor assistants on the requirement to document progress toward counselor status annually.
Add routine leadership review of counselor assistant files to confirm that annual progress documentation is completed and filed timely.
Responsible person:
Clinical Director
Human Resources
Director of Compliance
Completion date:
June 21, 2026
Monitoring method:
Counselor assistant personnel files will be reviewed monthly to verify that required annual documentation of progress toward counselor status is present and complete. At the end of each calendar year, all counselor assistants will be required to submit updated progress documentation to the facility director, and leadership will review files to confirm compliance.
Evidence maintained:
Updated personnel file for Employee #17
Annual counselor assistant progress documentation
Standardized progress form
Personnel file audit tool
Supervisor education or review records
Monthly compliance review records |
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to follow their written policies and procedures regarding the required components of the staff development program for agency personnel.
There were written policies and procedures indicating who is responsible and the time frames for completion of the following required components: completing an assessment of staff training needs, completing an overall plan for addressing those needs, ensuring a mechanism to collect feedback on completed trainings, and completing an annual evaluation of the overall training plan. There was no documentation provided indicating the completion of the staff training needs assessment, the overall plan to address the needs, the completion of feedback for completed trainings, and the annual evaluation of the overall training plan at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
LAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 704.11(a) ? Staff Development Procedure
1. Statement of the Deficiency
The facility's written policies and procedures regarding the required components of the staff development program were established but not executed. Specifically, the facility lacked documentation verifying the completion of:
An assessment of staff training needs.
An overall plan for addressing those needs.
A mechanism to collect feedback on completed trainings.
An annual evaluation of the overall training plan.
2. Corrective Action(s) Taken & Planned
To ensure immediate compliance and strengthen the facility's staff development process, Beacon Point Recovery Center has implemented the following corrective actions to align daily operations with established policies:
Completion of Needs Assessment:
A standardized Staff Training Needs Assessment survey will be distributed to all agency personnel. This assessment will identify competency gaps, state-mandated training requirements, and areas of professional interest across clinical, medical, and administrative departments.
Development of the Overall Training Plan:
Based on the aggregated data from the Needs Assessment, the facility will finalize a comprehensive 12-month Annual Training Matrix. This matrix will outline specific training topics, training methods, scheduled dates, and the internal or external educators responsible for delivery.
Implementation of Feedback Mechanism:
A standardized Post-Training Evaluation Form has been created. Effective immediately, this form will be distributed by hard copy or secure digital link at the conclusion of every facility-sponsored training event. Completion of the evaluation will be required for an employee to receive credit or certification for attending the training.
Annual Evaluation Scheduling:
A formal review of the staff development program will be completed annually. This evaluation will assess the overall effectiveness of the training plan by reviewing incident trends, staff training compliance, staff feedback, and post-training evaluation data to support continuous improvement.
3. Plan for Monitoring and Quality Assurance
To prevent recurrence and ensure sustained compliance, the following monitoring protocols have been established:
The Human Resources Department will maintain a centralized Staff Development Binder and corresponding digital repository containing the Annual Training Matrix, blank and completed Needs Assessments, blank and completed Post-Training Evaluation Forms, and annual staff development program evaluation documentation.
The Director of Compliance will conduct a quarterly internal audit of the Staff Development Binder to ensure all ongoing trainings have corresponding sign-in sheets and completed feedback forms. Any missing documentation will be immediately addressed with the appropriate department leadership.
4. Title of Person Responsible for Implementation
Director of Compliance
With oversight by the Executive Director/Facility Director
5. Target Completion Date
Needs Assessment Data Aggregated and Training Plan Finalized: July 23, 2026 |
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 personnel records, the facility failed to ensure individual training plans were developed annually, with input from both the employee and the supervisor, in one of twenty-two personnel records reviewed.
Employee #1 was hired as the project director on May 17, 2024. There was an individual training plan in the personnel record dated January 14, 2025; however, there was no documentation the plan was developed with input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 704.11(b) ? Individual Training Plan
Date of Inspection: April 10, 2026
1. Statement of the Deficiency
A review of twenty-two personnel records revealed that the facility failed to ensure individual training plans were developed annually with documented input from both the employee and the supervisor in one instance. Specifically, Employee #1 (Project Director, hired May 17, 2024) had an individual training plan dated January 14, 2025; however, the record lacked documentation demonstrating that the plan was developed with input from the supervisor.
2. Corrective Action(s) Taken & Planned
To correct the immediate deficiency and implement a more resilient documentation standard for all agency personnel, Beacon Point has taken the following actions:
Immediate Correction for Employee #1: A formal addendum will be attached to the January 14, 2025, Individual Training Plan for Employee #1. A documented review session will be held between Employee #1 and their direct supervisor (the Governing Body/Ownership). The addendum will include specific, written supervisor feedback regarding the employee's training trajectory and bear the dated signatures of both parties.
Revision of the Individual Training Plan (ITP) Form: The facility's standardized ITP document will be structurally revised. The new form will include a mandatory, designated section titled "Supervisor Input & Development Goals," alongside a required signature block for the direct supervisor. This physically prevents a training plan from being filed as "complete" without the supervisor's documented contribution.
Facility-Wide Record Review: The Human Resources department will initiate a retroactive audit of all active personnel files to ensure every current Individual Training Plan contains dual signatures and documented supervisor input. Any identified gaps will be corrected immediately via targeted review sessions.
3. Plan for Monitoring and Quality Assurance (Audit Process)
To ensure this documentation standard is consistently maintained and to prevent recurrence, the following audit process has been established:
New Hire & Annual Review Audits: The Human Resources Coordinator will review 100% of Individual Training Plans prior to filing them in the personnel record (both at the time of hire and during the annual performance review cycle). Any ITP missing the newly required "Supervisor Input" section or supervisor signature will be rejected and returned to the respective department head for immediate completion.
Monthly Compliance Audit: The Director of Compliance will conduct a randomized audit of 10% of active personnel files each month. This audit will specifically verify adherence to § 704.11(b), ensuring that the training plans reflect collaborative development.
4. Title of Person Responsible for Implementation
Director of Compliance
(With collaborative execution by the Human Resources Department)
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to ensure individual training plans were based upon an employee's previous education, experience, current job functions and job performance in five of twenty-two applicable personnel records reviewed.
Employee #1 was hired as the project director on May 17, 2024. The individual training plan dated January 14, 2025 was blank; thus, indicating the plan was not developed based upon the employee's previous education, experience, current job functions and job performance.
Employee #20 was hired as a behavioral health technician on April 17, 2023. The individual training plan dated 2025 was blank; thus, indicating the plan was not developed based upon the employee's previous education, experience, current job functions and job performance.
Employee #29 was hired as a behavioral health technician on March 11, 2024. The individual training plan dated 2025 was blank; thus, indicating the plan was not developed based upon the employee's previous education, experience, current job functions and job performance.
Employee #30 was hired as a behavioral health technician on January 19, 2026. The individual training plan dated 2025 was blank; thus, indicating the plan was not developed based upon the employee's previous education, experience, current job functions and job performance.
Employee #33 was hired as a behavioral health technician on February 20, 2025. The individual training plan dated 2025 was blank; thus, indicating the plan was not developed based upon the employee's previous education, experience, current job functions and job performance.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 704.11(b) ? Individual Training Plan (Content Requirements)
Date of Inspection: April 10, 2026
1. Statement of the Deficiency
A review of twenty-two personnel records revealed that the facility failed to ensure individual training plans were developed based upon an employee's previous education, experience, current job functions, and job performance in five instances. Specifically, the 2025 individual training plans for Employee #1 (Project Director), Employee #20 (BHT), Employee #29 (BHT), Employee #30 (BHT), and Employee #33 (BHT) were blank at the time of the inspection, failing to meet the regulatory standard for individualized staff development.
2. Corrective Action(s) Taken & Planned
To correct the immediate deficiency and ensure all future training plans are highly individualized and compliant with state standards, Beacon Point has implemented the following actions:
Immediate File Corrections: The blank 2025 Individual Training Plans for Employees #1, #20, #29, #30, and #33 will be immediately completed. Each plan will be actively filled out in collaboration with the employee's direct supervisor. The completed narratives will explicitly state how the assigned training goals correlate with the employee's resume (education and experience), current job description (job functions), and most recent evaluation (job performance).
ITP Form Enhancement: The facility's standardized Individual Training Plan document will be updated. The revised form will include four mandatory, distinct prompt sections:
Relation to Prior Education
Relation to Prior Experience
Relation to Current Job Functions
Relation to Recent Performance Metrics
This structural change physically prevents a supervisor from submitting a blank or generic plan, requiring them to address the specific DDAP criteria.
Supervisor Re-Training: All facility supervisors and department heads will undergo a mandatory in-service on how to properly execute the revised Individual Training Plan process, emphasizing the requirement to cross-reference an employee's personnel file when assigning training goals.
3. Plan for Monitoring and Quality Assurance (Audit Process)
To ensure this documentation standard is consistently maintained and to prevent recurrence, the following audit process has been established:
Pre-Filing Verification (HR Gatekeeping): The Human Resources department is now strictly prohibited from filing an Individual Training Plan into a personnel record if any of the four developmental criteria sections are left blank. Incomplete forms will be rejected and escalated to the Executive Director.
Monthly Compliance Audit: The Director of Compliance will conduct a randomized audit of 10% of active personnel files each month. This audit will specifically cross-reference the employee's ITP against their resume and job description to verify that the training goals are genuinely individualized.
4. Title of Person Responsible for Implementation
Director of Compliance
(With collaborative execution by the Human Resources Department and Department Supervisors)
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
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 and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in eight of twelve applicable personnel records reviewed.
Employee #10 was hired as a counselor assistant on December 2, 2024 and was promoted to counselor on December 7, 2025. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than December 2, 2025. There was no documentation indicating the completion of the TB/STD training as of the date of the inspection.
Employee #13 was hired as a counselor on August 14, 2024. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than August 14, 2025. There was no documentation indicating the completion of the HIV/AIDS training as of the date of the inspection.
Employee #20 was hired as a behavioral health technician on April 17, 2023. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than April 17, 2025. There was no documentation indicating the completion of both trainings as of the date of the inspection.
Employee #24 was hired as a behavioral health technician on September 6, 2022. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than September 6, 2024. There was no documentation indicating the completion of the TB/STD training as of the date of the inspection.
Employee #29 was hired as a behavioral health technician on March 11, 2024. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than March 11, 2026. There was no documentation indicating the completion of both trainings as of the date of the inspection.
Employee #39 was hired as a behavioral health technician on January 16, 2023. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than January 16, 2025. There was no documentation indicating the completion of the TB/STD training as of the date of the inspection.
Employee #40 was hired as a behavioral health technician on December 20, 2021. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than December 20, 2023. There was no documentation indicating the completion of the TB/STD training as of the date of the inspection.
Employee #41 was hired as a behavioral health technician on March 31, 2024. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than March 31, 2026. There was no documentation indicating the completion of the TB/STD training as of the date of the inspection.
This is a repeat citation from the May 1, 2024 and the April 25, 2025 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 704.11(c)(1) ? Mandatory Communicable Disease Training
Date of Inspection: April 10, 2026
1. Statement of the Deficiency
A review of personnel records and the Staffing Requirement Facility Summary Report revealed the facility failed to ensure staff completed a minimum of 6 hours of DDAP-approved HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the required regulatory timeframes (1 year for counselors/counselor assistants, 2 years for all other staff). This deficiency was observed in eight of twelve applicable personnel records (Employees #10, #13, #20, #24, #29, #39, #40, and #41). Furthermore, this is a repeat citation from the May 1, 2024, and April 25, 2025, annual licensing renewal inspections.
2. Corrective Action(s) Taken & Planned
Acknowledging that this is a repeat systemic failure, Beacon Point has recognized that previous manual tracking methods were insufficient. To achieve permanent compliance, the facility is completely restructuring the timeline and enforcement of this mandate:
Immediate Remediation of Deficient Records: Employees #10, #13, #20, #24, #29, #39, #40, and #41 have been immediately enrolled in the required DDAP-approved HIV/AIDS and TB/STD curriculums via the state's official training portal (TRAIN PA). They have been placed on strict administrative deadlines to provide their completion certificates to Human Resources.
Facility Policy Overhaul (The "90-Day Rule"): To eliminate the confusion of tracking different deadlines (1 year for clinical vs. 2 years for BHTs), Beacon Point has officially amended its internal Staff Development Policy. Effective immediately, ALL newly hired personnel, regardless of job title, must complete the required 10 hours of communicable disease training within their first 90 days of employment (during their probationary period).
Hard-Stop Scheduling Enforcement: The facility has implemented a "hard-stop" scheduling policy. If an employee's completion certificates for the HIV/AIDS and TB/STD modules are not physically present in their personnel file by Day 90 of employment, they will be automatically removed from the active staffing schedule without pay until the requirement is fulfilled.
3. Plan for Monitoring and Quality Assurance (Audit Process)
To ensure this aggressively accelerated timeline prevents future citations, the following audit process has been established:
Monthly Roster Cross-Reference: The Director of Compliance will conduct a monthly audit comparing the facility's active payroll roster against the "Staff Development Binder" to ensure 100% of staff past their 90-day probationary period have completed the state-approved curriculums.
4. Title of Person Responsible for Implementation
Director of Compliance
(With direct enforcement authority granted by the Executive Director to pull non-compliant staff from the schedule)
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
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 ensure all counselors completed at least 25 clock hours of annual training required for the position during the facility January 2025 through December 2025 training year in one of two applicable personnel records reviewed.
Employee #14 was hired as a counselor on January 25, 2021. There was documentation in the personnel record indicating only 15 hours of annual training was completed during the reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Citation:
28 Pa. Code § 704.11(f)(2) Training Requirements for Counselors
Deficiency:
Based on a review of personnel records, the facility failed to ensure all counselors completed at least 25 clock hours of annual training required for the position during the facility January 2025 through December 2025 training year in one of two applicable personnel records reviewed. Employee #14 was hired as a counselor on January 25, 2021. Documentation in the personnel record showed that only 15 hours of annual training were completed during the reviewed period.
Immediate correction:
The personnel file for Employee #14 will be reviewed immediately to confirm total training hours completed during the 2025 training year and to determine whether any additional training documentation is available. If training hours remain deficient, the employee will be scheduled to complete the missing annual training hours, and all documentation will be placed in the personnel file.
Corrective action steps:
Review Employee #14's personnel file to verify all completed training hours and place any missing training documentation in the file.
Schedule and complete any remaining annual training hours needed for Employee #14 to meet the required 25 clock hours.
Conduct an audit of all counselor personnel files to verify completion of required annual training hours for each counselor.
Implement a training hour tracking log for all counselors showing required hours, completed hours, training dates, and training topics.
Require periodic review of counselor training compliance throughout the year so deficiencies are identified before the annual deadline.
Educate supervisors and department leadership on the requirement that each counselor complete at least 25 clock hours of annual training.
Responsible person:
Clinical Director
Human Resources
Director of Compliance
Completion date:
June 21, 2026
Monitoring method:
Counselor training records will be reviewed monthly to verify completion of annual training requirements. The training hour tracking log will be updated routinely throughout the year, and leadership will review progress to ensure all counselors meet the required 25 clock hours before the end of the training year.
Evidence maintained:
Updated personnel file for Employee #14
Training certificates and attendance records
Counselor annual training hour tracking log
Personnel file audit tool
Supervisor education or review records
Monthly compliance review records |
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 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.
At the time of the inspection, which was conducted on April 8, 2026 between 11:00 AM and 12:00 PM and April 9, 2026 between 10:00 AM and 11:00 AM, the following health and/or safety hazards to clients and staff were observed:
-The reception area on the 1st floor of the Annex building had an open electrical junction box and exposed wiring.
-The cafeteria on the 3rd floor of the Annex building had a broken drink appliance with wiring and tubing exposed.
-Several spots within the common areas, the community bathroom, and outside bedroom #7 on the 5th floor of the Annex building had evidence of water damage, including what appeared to be mold and mildew, and damaged ceilings.
-Bedroom #3 on the 5th floor of the Annex building had a broken windowpane in it.
-Several spots within the common areas, the community bathroom, and bedroom #'s 1, 5, and 6 on the 6th floor of the Annex building had evidence of water damage, including what appeared to be mold and mildew, and damaged ceilings
-The 3rd floor cafeteria of the Main building had several cafeteria tables that were unsteady and had paper towels and/or cardboard stuffed under the legs to balance them out.
-The 3rd floor cafeteria of the Main building had loose flooring around the serving station area.
-The 3rd floor cafeteria of the Main building had dirt, trash, and debris strewn about on the floor.
-The 6th floor of the Main building had a hallway railing, located near the elevator, that was loose and not completely affixed to the wall.
-Bedroom #402 of the Main building had graffiti on one of the walls.
-There was trash and garbage littered throughout each floor of the Annex building.
This is a repeat citation from the April 25, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Citation: 28 Pa. Code § 705.2(2)
Building Exterior and Grounds / Physical Plant Safety
Citation:
28 Pa. Code § 705.2(2) requires the residential facility to keep the grounds 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, grounds, and yard must be free of hazards.
Deficiency:
During the physical plant inspection conducted on April 8, 2026, and April 9, 2026, the facility was cited for failing to maintain areas of the Main and Annex buildings in a clean, safe, sanitary, and good state of repair. Observed concerns included exposed wiring, a broken drink appliance with exposed wiring/tubing, water damage with suspected mold/mildew and damaged ceilings, a broken windowpane, unstable cafeteria tables, loose flooring, dirt/trash/debris, a loose hallway railing, graffiti, and trash throughout the Annex building. This was identified as a repeat citation from the April 25, 2025 annual licensing renewal inspection.
Immediate Correction:
Upon identification, facility leadership initiated immediate safety measures. Exposed wiring areas were secured and reported for repair. The broken drink appliance was removed from service. Areas with water damage or suspected mold/mildew were reported for repair and restricted as needed. The broken windowpane, loose railing, loose flooring, graffiti, unstable cafeteria tables, and trash/debris concerns were reported to operations, maintenance, and environmental services for immediate correction. Environmental services completed cleaning of affected areas, and unstable tables were removed from client use.
Corrective Action Steps:
Maintenance tracking and documentation
All cited physical plant concerns will be entered into the facility maintenance tracking log. Each entry will include the specific location, description of the issue, date identified, person or vendor assigned, corrective action required, target completion date, final completion date, and before-and-after photo documentation. This will allow leadership to track each item through full resolution and prevent open items from being missed.
Contractor secured for repairs
Beacon Point Recovery Center has already secured a qualified contractor to address the identified physical plant concerns. The contractor will work with facility leadership, maintenance, and operations to complete repairs related to electrical hazards, water-damaged areas, damaged ceilings, flooring concerns, window repair, railing repair, and other cited building deficiencies. Any repair requiring specialized licensure, such as electrical work or environmental remediation, will be completed by appropriately qualified personnel or subcontractors.
Electrical hazards and exposed wiring
The exposed wiring and open electrical junction box will be repaired by qualified maintenance personnel or an outside electrical vendor. Until repairs are completed, affected areas will remain secured or restricted as needed to prevent access by clients, staff, or visitors. Final repair will be documented with work orders and photo evidence.
Broken drink appliance
The broken drink appliance with exposed wiring and tubing will remain out of service until it is repaired, replaced, or permanently removed. The appliance will not be returned to client or staff use unless it is confirmed to be safe, functional, and free from exposed wiring, tubing, or other hazards.
Water damage, damaged ceilings, and suspected mold/mildew
All areas with water damage, damaged ceilings, or suspected mold/mildew will be assessed by the secured contractor and facility leadership. The source of the water damage will be identified and corrected. Damaged ceiling materials will be repaired or replaced, affected surfaces will be cleaned, and any suspected mold or mildew will be remediated as needed. Impacted rooms or common areas will be restricted from client use when necessary until they are safe, sanitary, and in good repair.
Broken windowpane
The broken windowpane in the Annex building will be repaired or replaced. The affected room will not be returned to client use until the window is fully repaired, secure, and free of broken glass or other safety concerns.
Unstable cafeteria tables
Unstable cafeteria tables will be repaired, replaced, or removed from service. Temporary fixes such as cardboard, paper towels, or other makeshift balancing methods will not be permitted. Tables will be inspected for stability before being returned to use.
Loose flooring and loose hallway railing
The loose flooring around the cafeteria serving station and the loose hallway railing near the elevator will be repaired by maintenance or the secured contractor. These areas will be inspected after repair to ensure they are safe and no longer present a trip, fall, or injury hazard.
Graffiti removal and wall repair
Graffiti will be removed from bedroom #402, and the affected wall surface will be cleaned, repaired, or repainted. Room condition checks will be included in ongoing environmental rounds to identify wall damage, graffiti, or needed repairs earlier.
Trash, debris, and sanitation concerns
Environmental services will complete daily cleaning and trash removal throughout the Main and Annex buildings. Operations leadership will reinforce expectations for routine trash removal, floor cleaning, and debris control in client-accessible areas. Any missed cleaning concerns will be reported to environmental services and tracked until corrected.
Formal physical plant rounding process
Beacon Point Recovery Center will implement a formal physical plant rounding process to prevent recurrence. This will include daily observations by unit leadership and environmental services, weekly documented inspections by the Director of Operations or designee, and monthly leadership review by the Executive Director, Director of Operations, and Director of Compliance. Findings will be documented, assigned for correction, tracked to completion, and reviewed through the facility's quality assurance process.Responsible Person:
Primary responsibility: Executive Director / Director of Nursing
Operational responsibility: Director of Operations
Compliance oversight: Director of Compliance
Additional support: Maintenance, environmental services, food service, and unit supervisors.
Completion Date:
Immediate safety corrections: April 26, 2026
Full corrective action completion: May 15, 2026
Ongoing monitoring initiated: April 29, 2026
Monitoring Method:
The Director of Operations or designee will complete weekly physical plant inspections of the Main and Annex buildings for 90 days, then monthly for 12 months. Unit supervisors and environmental services will report safety or sanitation concerns daily. The Executive Director, Director of Operations, and Director of Compliance will review open work orders, repeat issues, and completion status monthly through the facility's quality assurance process.
Evidence Maintained:
The facility will maintain maintenance work orders, vendor invoices, before-and-after photos, environmental cleaning logs, weekly inspection checklists, monthly leadership review documentation, repair records, remediation documentation if applicable, and quality assurance meeting minutes as evidence of correction and sustained compliance |
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, conducted on April 8, 2026 between 11:00 AM and 12:00 PM, 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, there were no operable soap dispensers provided in several bathrooms, which are located in the Main building's 4th, 5th, 6th, and 7th floor client rooms. The client room #'s were 401, 402, 403, 404, 405, 406, 407, 408, 409, 410, 411, 412, 413, 501, 502, 505, 506, 507, 508, 509, 510, 512, 601, 602, 603, 604, 605, 606, 607, 608, 609, 610, 611, 612, 701, 702, 703, 704, 705, 706, 707, 709, 710, 711, 712, and 713.
Additionally, there were missing, empty, or broken paper towel dispensers provided in several bathrooms, which are located in the Main building's 4th, 5th, 6th, and 7th floor client rooms. The client room #'s were 408, 412, 502, 504, 608, 610, 701, 702, 704, 706, 710, 712, as well as also in the staff restroom, located on the 3rd floor.
Also, there was no wall mirror provided in the bathroom of client room 610, which is located on the Main building's 6th floor.
This is a repeat citation from the April 25, 2025 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DDAP Plan of Correction
Citation: 28 Pa. Code § 705.6(2)
Bathrooms
Citation:
28 Pa. Code § 705.6(2) requires the residential facility to provide a sink, wall mirror, operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
Deficiency:
Based on the physical plant inspection conducted on April 8, 2026, between 11:00 AM and 12:00 PM, the facility failed to provide operable soap dispensers, paper towels or mechanical drying equipment, and a wall mirror in all required bathrooms.
At the time of inspection, several bathrooms in the Main building client rooms on the 4th, 5th, 6th, and 7th floors did not have operable soap dispensers. The cited rooms were:
401, 402, 403, 404, 405, 406, 407, 408, 409, 410, 411, 412, 413, 501, 502, 505, 506, 507, 508, 509, 510, 512, 601, 602, 603, 604, 605, 606, 607, 608, 609, 610, 611, 612, 701, 702, 703, 704, 705, 706, 707, 709, 710, 711, 712, and 713.
Several bathrooms also had missing, empty, or broken paper towel dispensers. The cited rooms were:
408, 412, 502, 504, 608, 610, 701, 702, 704, 706, 710, 712, and the 3rd floor staff restroom.
The bathroom in client room 610 did not have a wall mirror.
This was identified as a repeat citation from the April 25, 2025 annual licensing renewal inspection.
Immediate Correction:
Facility leadership immediately reviewed the cited bathrooms and initiated correction of missing, empty, broken, or inoperable bathroom supplies and fixtures.
Operable soap dispensers and paper towel dispensers were added, repaired, refilled, or replaced where needed. The missing wall mirror in room 610 was identified for installation. Any bathroom missing required items was prioritized for correction to ensure each bathroom contained the required sink, wall mirror, operable soap dispenser, and paper towels or mechanical drying equipment.
Corrective Action Steps:
Bathroom inventory audit
The Director of Operations or designee will complete a full bathroom inventory audit of all client and staff bathrooms in the Main and Annex buildings. The audit will verify the presence and functionality of the required items in each bathroom: sink, wall mirror, operable soap dispenser, and paper towels or mechanical dryer.
Soap dispenser correction
All cited bathrooms will be supplied with operable soap dispensers. Broken or missing dispensers will be replaced. Empty dispensers will be refilled immediately. Soap dispensers will be checked weekly by environmental services and unit staff.
Paper towel dispenser correction
All cited bathrooms with missing, empty, or broken paper towel dispensers will be corrected. Dispensers will be repaired, replaced, and stocked with individual paper towels. Where repair is not immediately possible, temporary individual paper towels will be made available until the dispenser is fully replaced or repaired.
Wall mirror installation
A wall mirror will be installed in the bathroom of client room 610. The bathroom will be inspected after installation to confirm compliance with 28 Pa. Code § 705.6(2).
Supply par levels
The facility will establish minimum par levels for soap, paper towels, and replacement dispensers. Environmental services and operations will maintain an adequate supply inventory so bathrooms do not go without required hygiene items.
Daily bathroom checks
Environmental services will complete daily bathroom checks to confirm soap dispensers are operable, paper towels are stocked, and required fixtures are intact. Any missing, empty, broken, or inoperable item will be reported and corrected the same day whenever possible.
Weekly documented bathroom inspections
The Director of Operations or designee will complete weekly documented inspections of client and staff bathrooms for 90 days. The inspection will include verification of sinks, mirrors, soap dispensers, and paper towels or mechanical dryers.
Repeat citation prevention
Because this is a repeat citation, bathroom compliance will be added to the facility's ongoing physical plant rounding tool. Leadership will review trends, missed items, and delayed repairs through the quality assurance process.
Responsible Person:
Primary Responsible Person:
Executive Director / Director of Nursing
Operational Responsible Person:
Director of Operations
Compliance Oversight:
Director of Compliance
Additional Responsible Parties:
Environmental Services, Maintenance, Unit Supervisors, and Department Managers
Completion Date:
Ongoing monitoring initiated: April 29, 2026
Monitoring Method:
The Director of Operations or designee will conduct weekly documented bathroom inspections for 90 days, then monthly for 12 months. Environmental services will conduct daily checks to ensure soap dispensers are operable, paper towels are stocked, and bathroom fixtures remain intact.
The Executive Director, Director of Operations, and Director of Compliance will review bathroom inspection results monthly through the quality assurance process. Any repeated issue will be assigned for corrective action with a responsible person and completion date.
Evidence Maintained:
The facility will maintain the following evidence of correction and ongoing compliance:
Completed bathroom audit forms
Daily environmental services checklists
Weekly bathroom inspection logs
Maintenance work orders
Purchase receipts for soap dispensers, paper towel dispensers, paper towels, and mirrors
Before and after photos of corrected bathrooms
Documentation of mirror installation in room 610
Quality assurance meeting minutes
Corrective action tracking logs
Monthly leadership review documentation |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection, conducted on April 8, 2026 between 11:00 AM and 12:00 PM, the facility failed to ensure toilet paper was provide at each toilet at all times.
At the time of the inspection, there was toilet paper missing from the Main building's bathrooms in client room #'s 502, 504, 704, 710, and 712. Also, in the Main building, the toilet paper dispenser was missing, and the toilet paper roll was sitting on the floor in the bathroom in client room #610. Additionally, the Main building's 3rd floor staff bathroom was missing a toilet paper dispenser, and the toilet paper roll was sitting on the top of the tank.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
DDAP Plan of Correction
Citation: 28 Pa. Code § 705.6(6)
Bathrooms: Toilet Paper Availability
Citation:
28 Pa. Code § 705.6(6) requires the residential facility to provide toilet paper at each toilet at all times.
Deficiency:
Based on the physical plant inspection conducted on April 8, 2026, between 11:00 AM and 12:00 PM, the facility failed to ensure toilet paper was provided at each toilet at all times.
At the time of inspection, toilet paper was missing from the Main building bathrooms in client rooms:
502, 504, 704, 710, and 712.
Additionally, the toilet paper dispenser was missing in client room 610, and the toilet paper roll was sitting on the floor. The Main building 3rd floor staff bathroom was also missing a toilet paper dispenser, and the toilet paper roll was sitting on top of the toilet tank.
These findings were reviewed with facility staff during the licensing process.
Immediate Correction:
Facility leadership immediately directed environmental services and maintenance to correct the identified bathroom supply and dispenser issues. Toilet paper was placed at each cited toilet, and missing or damaged toilet paper dispensers were reported for immediate replacement.
Bathrooms with toilet paper rolls placed on the floor or toilet tank were corrected so that toilet paper is maintained in a sanitary and accessible manner. Client rooms 610, 502, 504, 704, 710, 712, and the 3rd floor staff bathroom were prioritized for correction.
Corrective Action Steps:
Immediate restocking of cited bathrooms
Toilet paper will be placed at each toilet in client rooms 502, 504, 704, 710, and 712. Environmental services will verify that each toilet has toilet paper available before the area is cleared as corrected.
Replacement of missing dispensers
Missing toilet paper dispensers in client room 610 and the 3rd floor staff bathroom will be replaced. Toilet paper rolls will not be stored on the floor, toilet tank, sink, windowsill, or any other unsanitary surface.
Bathroom supply audit
The Director of Operations or designee will complete a bathroom supply audit of all client and staff bathrooms in the Main and Annex buildings to confirm that toilet paper is present at every toilet and properly secured in a dispenser.
Daily environmental services checks
Environmental services will check all client and staff bathrooms daily to confirm toilet paper is available at each toilet. Any missing supply or broken dispenser will be corrected or reported immediately.
Par level supply system
The facility will maintain adequate par levels of toilet paper and replacement dispensers to ensure supplies are available at all times. Supply levels will be reviewed by operations or environmental services leadership to prevent stockouts.
Shift-based reporting
Unit staff and supervisors will report missing toilet paper, broken dispensers, or unsanitary placement of supplies during routine rounds. Concerns will be entered into the maintenance or environmental services log and corrected the same day whenever possible.
Weekly documented inspections
The Director of Operations or designee will complete weekly documented bathroom inspections for 90 days. The inspection will verify that each toilet has toilet paper, dispensers are present and functional, and supplies are maintained in a sanitary manner.
Ongoing compliance review
Bathroom supply compliance will be included in the facility's physical plant rounding process and reviewed through the quality assurance process to identify trends, repeated issues, or delayed corrections.
Responsible Person:
Primary Responsible Person:
Executive Director / Director of Nursing
Operational Responsible Person:
Director of Operations
Compliance Oversight:
Director of Compliance
Additional Responsible Parties:
Environmental Services, Maintenance, Unit Supervisors, and Department Managers
Completion Date:
Immediate toilet paper restocking: April 26, 2026
Bathroom supply audit completed: May 3, 2026
Ongoing monitoring initiated: April 29, 2026
Monitoring Method:
Environmental services will complete daily checks of all client and staff bathrooms to ensure toilet paper is available at each toilet at all times. The Director of Operations or designee will complete weekly documented bathroom inspections for 90 days, then monthly for 12 months.
The Executive Director, Director of Operations, and Director of Compliance will review bathroom inspection findings monthly through the facility's quality assurance process. Any repeated issue will be assigned corrective action with a responsible person and target completion date. |
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, conducted on April 8, 2026 between 11:00 AM and 12:00 PM, and on April 9, 2026 between 10:00 AM and 11:00 AM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
At the time of the inspection, there was a water-stained ceiling tile above the shower in the client bathroom # 508, which is located in the Main building. Also, the community bathrooms located on the Annex building ' s 6th floor had broken ceiling tiles with construction materials hanging down from the ceiling, peeling paint, broken shower curtains, and what appears to be mold or mildew. Additionally, the community bathrooms, located on the 5th floor of the Annex building, had what appeared to be mold or mildew on the wall and above the shower stall. Lastly, the community bathroom, located on the 1st floor of the Annex building, had toilet paper and trash littered on the floor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 705.6(7) ? Bathrooms (Functional, Clean, and Sanitary)
Date of Inspection: April 8-9, 2026
1. Statement of the Deficiency
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times. Specific observations included:
Main Building Room 508: Water-stained ceiling tile above the shower.
Annex Building 6th Floor Community Bathrooms: Broken ceiling tiles with hanging construction materials, peeling paint, broken shower curtains, and suspected mold/mildew.
Annex Building 5th Floor Community Bathrooms: Suspected mold/mildew on the walls and above the shower stall.
Annex Building 1st Floor Community Bathroom: Toilet paper and trash littered on the floor.
2. Corrective Action(s) Taken & Planned
To correct the immediate physical deficiencies and establish a proactive facility management system, Beacon Point Recovery Center has executed the following actions:
Immediate Environmental Remediation:
Main Building Room 508: The water-stained ceiling tile was replaced, and the plumbing above was inspected to ensure no active leaks.
Annex Building 6th Floor: Damaged ceiling tiles and hanging construction debris were removed and replaced. The walls were scraped and repainted with moisture-resistant paint, broken shower curtains were replaced, and suspected mold/mildew was professionally treated and removed.
Annex Building 5th Floor: The walls and shower stall ceilings were deeply sanitized and treated to remove suspected mold/mildew.
Annex Building 1st Floor: The bathroom was immediately deep-cleaned, and all trash and debris were removed.
Implementation of Daily Walkthrough Sheets:
To proactively identify and resolve environmental hazards before they accumulate, all floors and rooms will maintain a dedicated maintenance log and daily walkthrough sheets. Behavioral Health Technicians and Housekeeping staff are required to conduct documented environmental rounds at the start of each shift, actively monitoring and logging what is operational and what requires repair in every bathroom.
Centralized Maintenance Log:
Any broken items, sanitary issues, or needed repairs identified on the walkthrough sheets will be immediately entered into a centralized digital Maintenance Work Order Log. This will alert the Facilities Department for timely response and follow-up.
3. Plan for Monitoring and Quality Assurance
To ensure sustained environmental compliance and accountability across all shifts, the following auditing processes have been established:
Daily Supervisor Review:
The Facilities Manager and Shift Supervisors will review the walkthrough sheets and the centralized Maintenance Work Order Log at the end of each day to ensure all identified work orders are actively being addressed.
Weekly Environmental Rounds:
The Director of Compliance will conduct a weekly physical walkthrough of a randomized selection of patient rooms and community bathrooms, directly comparing the physical conditions to the recorded walkthrough sheets to ensure staff are accurately reporting issues.
4. Title of Person Responsible for Implementation
Director of Compliance
With collaborative execution by the Facilities Manager and Housekeeping Supervisors
5. Target Completion Date
Immediate Environmental Repairs, including tiles, suspected mold/mildew treatment, paint, and trash removal:
Full Compliance Reached: June 21, 2026. |
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, conducted on April 8, 2026 between 11:00 AM and 12:00 PM, the facility failed to ensure all facility heaters were permanently mounted or installed.
At the time of the inspection, there was a portable space heater located in the Main building's 3rd floor nursing dispensing station.
This is a repeat citation from the April 25, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 705.8(2) ? Heating and Cooling (Portable Heaters)
Date of Inspection: April 8-9, 2026
1. Statement of the Deficiency
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed. Specifically, a portable space heater was located in the Main Building 3rd-floor nursing dispensing station.
This is a repeat citation from the April 25, 2025 annual licensing renewal inspection, indicating previous corrective measures were insufficient.
2. Corrective Action(s) Taken & Planned
Recognizing this as a repeat deficiency, Beacon Point Recovery Center understands that simply removing the observed heater does not resolve the systemic issue. To achieve permanent compliance, the facility has taken the following comprehensive actions:
Immediate Removal and Facility Sweep:
The portable space heater in the 3rd-floor nursing dispensing station was immediately removed from the premises. Following this, the Facilities Manager conducted a full facility-wide sweep of all offices, nursing stations, patient rooms, and staff work areas to identify and remove any other unauthorized portable heating devices.
Policy Enforcement and Staff Memo:
A mandatory internal memo has been distributed to all department heads and staff. The memo outlines the DDAP prohibition on portable space heaters and identifies them as fire and life-safety hazards. The memo also states that bringing a portable heater onto the premises may result in corrective action in accordance with facility policy.
Integration with Daily Rounds:
Monitoring for unauthorized appliances has been permanently added to the Daily Walkthrough Sheets. Shift Supervisors are required to check for and document the absence of portable heaters during environmental rounds.
3. Plan for Monitoring and Quality Assurance
To ensure this repeat citation does not recur, the following auditing process has been implemented:
Monthly Environmental Sweeps:
The Director of Compliance will conduct unannounced, randomized environmental sweeps of staff workspaces, nursing stations, patient areas, and other facility locations at least once per month to visually verify compliance with the no-portable-heater policy.
Any unauthorized portable heater identified during environmental rounds or monthly sweeps will be removed immediately, documented on the environmental inspection log, and addressed with the appropriate department leadership.
4. Title of Person Responsible for Implementation
Director of Compliance
With collaborative execution by the Facilities Manager and Director of Nursing
5. Target Completion Date
Immediate Removal and Facility Sweep: Completed April 8, 2026.
Staff Memo Distributed: On or before May 7, 2026.
Full Compliance Reached: June 21, 2026. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection, conducted on April 9, 2026 between 10:00 AM and 11:00 AM, the facility failed to ensure there was no infestation of rodents and insects.
At the time of the inspection, in the Annex building's 6th floor, there were multiple windowsills that had dead insects lying on them.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 705.9(1) ? General Safety and Emergency Procedures (Pest Control)
Date of Inspection: April 9, 2026
1. Statement of the Deficiency
Based on a physical plant inspection conducted on April 9, 2026, between 10:00 AM and 11:00 AM, the facility failed to ensure it was free of insect infestation. Specifically, multiple windowsills on the 6th floor of the Annex Building had dead insects lying on them at the time of the inspection.
2. Corrective Action(s) Taken & Planned
To correct the immediate sanitary deficiency and ensure a pest-free environment is consistently maintained, Beacon Point Recovery Center has implemented the following actions:
Immediate Environmental Cleaning:
Upon notification during the inspection, Housekeeping staff were immediately dispatched to the 6th floor of the Annex Building to thoroughly clean and sanitize all windowsills and baseboards. A facility-wide sweep was subsequently conducted to ensure no other dead or living insects were present on windowsills in other units.
Professional Extermination and Exclusion Assessment:
The facility's contracted commercial pest control vendor was dispatched to conduct a targeted inspection of the 6th floor to identify the species of insect and locate any potential points of entry, including compromised window seals or screens. A preventative perimeter treatment was applied to the exterior and interior areas of the Annex Building.
3. Plan for Monitoring and Quality Assurance
To ensure sustained environmental compliance and prevent recurrence, the following auditing processes have been established:
Weekly Environmental Rounds:
The Operations Supervisor will include windowsill inspections and pest-control verification as a dedicated line item during weekly physical walkthroughs of the facility.
Any evidence of insects, pest activity, compromised screens, window gaps, or sanitation concerns will be documented on the environmental inspection log and immediately referred to the Facilities Manager, Housekeeping Supervisor, or pest control vendor for corrective action.
4. Title of Person Responsible for Implementation
Director of Compliance
With collaborative execution by the Facilities Manager and Housekeeping Supervisor
5. Target Completion Date
Immediate Cleaning Completed: April 9, 2026.
Exterminator Assessment and Treatment Completed: On or before April 15, 2026.
Housekeeping Checklist Update and Audit
Full Compliance Reached: June 21, 2026. |
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 conducted on April 8, 2026 between 11:00 AM and 12:00 PM, the facility failed to limit smoking to designated areas.
At the time of the inspection, there was evidence of cigarette smoking, including a strong smoke smell and the presence of cigarette ashes, in the bathrooms located in the Main building's client room #'s 402, 404, 413, 602, and 608.
This is a repeat citation from the April 25, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 705.9(3) ? General Safety and Emergency Procedures (Smoking)
Date of Inspection: April 8, 2026
1. Statement of the Deficiency
Based on a physical plant inspection conducted on April 8, 2026, the facility failed to strictly limit smoking to designated smoking areas. Evidence of indoor cigarette smoking, specifically a strong smoke odor and the presence of cigarette ashes, was discovered in the bathrooms of the Main Building client rooms #402, #404, #413, #602, and #608.
This is a repeat citation from the April 25, 2025 annual licensing renewal inspection.
2. Corrective Action(s) Taken & Planned
Acknowledging that this is a repeat citation indicating a breakdown in behavioral enforcement and milieu management, Beacon Point Recovery Center has implemented new protocols to eliminate indoor smoking:
Immediate Environmental Remediation and Sweeps:
The bathrooms in rooms #402, #404, #413, #602, and #608 were immediately deep-cleaned and sanitized to remove all ashes and residual smoke odor. Simultaneously, a targeted facility-wide contraband sweep was conducted by Behavioral Health Technicians to confiscate all unauthorized lighters, matches, and loose tobacco products from patient rooms.
Clinical and Behavioral Intervention:
The patients occupying the cited rooms were immediately engaged by the clinical team. Behavioral contracts were implemented outlining that further indoor smoking violations may result in administrative action, up to and including administrative discharge, due to the fire and life-safety risk posed to the facility.
Enhanced Contraband Control:
The facility has revised its lighter and smoking materials policy. Patients are no longer permitted to keep lighters or matches on their person or in their rooms. All ignition sources are held securely at the Behavioral Health Technician station and are only distributed during scheduled, supervised smoke breaks in the designated outdoor smoking area.
Facility Hardening:
To provide an environmental deterrent, the facility has approved a work order to upgrade smoke detectors in patient bathrooms to tamper-resistant units that will alert the fire alarm system if smoking or vaping occurs.
3. Plan for Monitoring and Quality Assurance
To ensure patient compliance and prevent recurrence, the following monitoring processes have been implemented:
Targeted Behavioral Health Technician Rounding:
Behavioral Health Technicians conducting standard 30-minute patient safety rounds are required to complete a visual and odor check of bathroom spaces for evidence of smoking, when clinically appropriate and consistent with privacy and safety expectations. This has been added as a specific item on the electronic rounding logs.
Randomized Room Searches:
The Director of Compliance will coordinate with the Director of Nursing to complete unannounced, randomized room and bathroom sweeps for smoking contraband at least twice per month.
Any evidence of indoor smoking, smoking materials, lighters, matches, ashes, smoke odor, or tampering with smoke detectors will be documented and addressed immediately by the appropriate department leadership.
4. Title of Person Responsible for Implementation
Director of Compliance
With collaborative execution by the Director of Nursing and Behavioral Health Technician Supervisors
5. Target Completion Date
Immediate Deep Cleaning and Contraband Sweep: Completed April 8, 2026.
Contraband Policy Revision and Behavioral
Full Compliance Reached: June 21, 2026. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, conducted on April 9, 2026 between 10:00 AM and 11:00 AM, the facility failed to maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
At the time of the inspection, the walkway to the side entrance of the Annex building has an inclined ramp and the railing was broken off, with sharp metal edges exposed, and leaning against the side of the building.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 705.10(a)(1)(iii) ? Fire Safety (Exits, Handrails, and Railings)
Date of Inspection: April 9, 2026
1. Statement of the Deficiency
Based on a physical plant inspection conducted on April 9, 2026, the facility failed to maintain each ramp, interior stairway, and outside steps exceeding two steps with a well-secured handrail. Specifically, the walkway to the side entrance of the Annex Building had an inclined ramp where the railing was completely broken off, exposed sharp metal edges, and was found leaning against the side of the building.
2. Corrective Action(s) Taken & Planned
Because broken exterior egress routes pose a life-safety and injury hazard, Beacon Point Recovery Center took immediate action to secure the area and implement permanent structural repairs:
Immediate Hazard Mitigation:
Upon discovery during the inspection, the broken railing with sharp metal edges was immediately removed from the premises by the Maintenance Team and safely discarded. The inclined ramp was temporarily blocked off with high-visibility caution tape and signage redirecting foot traffic to the primary, structurally sound entrances to prevent immediate injuries.
Permanent Structural Repair:
A licensed commercial metal fabricator/contractor was contacted to complete permanent repair. A new, code-compliant metal handrail will be permanently anchored into the concrete walkway of the Annex Building side entrance to ensure it is secure and free of sharp edges or structural defects.
Expansion of Walkthrough Protocols:
The Daily Walkthrough Sheets have been amended to include exterior perimeter and egress routes. Staff conducting these rounds must visually inspect all exterior handrails, porches, ramps, and egress routes to ensure they remain secured and free of hazards.
3. Plan for Monitoring and Quality Assurance
To ensure exterior egress safety is continuously maintained and to prevent degradation of the physical plant, the following monitoring processes are in place:
Daily Perimeter Checks:
The Facilities Manager or designated Shift Supervisor will review the daily walkthrough logs to ensure exterior perimeter checks are completed. Any loose, broken, sharp-edged, or unstable railing will be immediately entered into the Maintenance Work Order Log and flagged for repair.
Weekly Environmental Rounds:
The Director of Compliance will physically inspect the newly installed Annex Building handrail, as well as exterior stairs, ramps, porches, and egress routes across the facility, during weekly environmental walkthroughs.
Any identified concern will be documented, assigned for correction, tracked through completion, and reviewed by facility leadership.
4. Title of Person Responsible for Implementation
Director of Compliance
With collaborative execution by the Facilities Manager
5. Target Completion Date
Immediate Hazard Removal and Egress Rerouting: Completed April 9, 2026.
Full Compliance Reached: June 21, 2026. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, conducted on April 8, 2026 between 11:00 AM and 12:00 PM, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
At the time of the inspection, there were multiple fire extinguishers, located in the hallway and near the smoking room on the 7th floor of the Main building, that were missing inspection tags.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 705.10 ? Fire Safety (Extinguisher Maintenance)
Date of Inspection: April 8, 2026
1. Statement of the Deficiency
Based on a physical plant inspection conducted on April 8, 2026, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or a certified fire extinguisher company. Specifically, multiple fire extinguishers located in the hallway and near the smoking room on the 7th floor of the Main Building were found to be missing their required annual inspection tags.
2. Corrective Action(s) Taken & Planned
Because unverified fire suppression equipment is a life-safety hazard, Beacon Point Recovery Center implemented an immediate response to correct the missing documentation and establish a tracking system:
Immediate Vendor Dispatch and Remediation:
The facility's contracted commercial fire protection vendor was dispatched to the Main Building on the day of the inspection. The vendor conducted a full inspection, pressure check, and re-tagging of the deficient extinguishers on the 7th floor to certify they were operational.
Facility-Wide Fire Extinguisher Audit:
While on site, the fire protection vendor, accompanied by the Facilities Manager, conducted a full facility-wide audit of every fire extinguisher across both the Main Building and Annex Building to ensure no other tags were missing or expired.
The audit verified that:
Each extinguisher was securely mounted.
Each pressure gauge was in the proper operating range.
Each annual inspection tag was present and legible.
Digital Preventative Maintenance Alerts:
The Facilities Manager entered the expiration month for all facility fire extinguishers into the centralized digital Maintenance Work Order Log. The system is programmed to provide advance alerts to the Facilities Manager, Director of Compliance, and appropriate facility leadership prior to the annual vendor inspection deadline.
3. Plan for Monitoring and Quality Assurance
To maintain ongoing compliance with local and state fire safety requirements, the following auditing processes have been implemented:
Monthly Fire Extinguisher Checks:
In accordance with applicable fire extinguisher inspection standards, the Facilities Manager will conduct and document a physical inspection of all fire extinguishers every 30 days. The inspection will verify that each extinguisher is mounted, accessible, charged, tagged, and free from damage or tampering.
Weekly Environmental Rounds:
The Director of Compliance will spot-check extinguisher tags during weekly environmental walkthroughs of the facility to confirm that monthly inspection logs align with the physical environment.
Any missing, damaged, expired, or illegible fire extinguisher tag will be documented immediately, reported to the Facilities Manager, and corrected through the contracted fire protection vendor as needed.
4. Title of Person Responsible for Implementation
Director of Compliance
With collaborative execution by the Facilities Manager
5. Target Completion Date
Immediate Vendor Inspection and Facility Sweep:
Full Compliance Reached: June 21, 2026. |
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 twenty-two of thirty-one applicable personnel records reviewed.
Employee #5 was hired as a counselor on September 17, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #6 was hired as a counselor on September 9, 2025. There was documentation of the completion of a fire extinguisher training; however, the training was not completed until January 8, 2026.
Employee #7 was hired as a counselor on February 24, 2026. There was documentation of the completion of a fire extinguisher training; however, the training was not completed until March 17, 2026.
Employee #9 was hired as a counselor on October 27, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #19 was hired as a behavioral health technician on September 26, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #21 was hired as a behavioral health technician on April 9, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #22 was hired as a behavioral health technician on August 11, 2025. There was documentation of the completion of a fire extinguisher training; however, the training was not completed until December 4, 2025.
Employee #23 was hired as a behavioral health technician on May 12, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #25 was hired as a behavioral health technician on November 3, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #26 was hired as a behavioral health technician on September 30, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #27 was hired as a behavioral health technician on July 25, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment..
Employee #28 was hired as a behavioral health technician on December 12, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #30 was hired as a behavioral health technician on January 19, 2026. There was documentation of the completion of a fire extinguisher training in 2026; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #31 was hired as a behavioral health technician on March 25, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #32 was hired as a behavioral health technician on February 20, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #33 was hired as a behavioral health technician on March 12, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #34 was hired as a behavioral health technician on February 11, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #35 was hired as a behavioral health technician on February 10, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #36 was hired as a behavioral health technician on February 18, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #37 was hired as a behavioral health technician on March 4, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #38 was hired as a behavioral health technician on February 11, 2026. There was documentation of the completion of a fire extinguisher training in 2026; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
Employee #42 was hired as a behavioral health technician on September 28, 2025. There was documentation of the completion of a fire extinguisher training in 2025; however, there was no exact date or training certificate to verify if the training was completed upon staff employment.
This is a repeat citation from the May 1, 2024 and April 25, 2025 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 705.10(c)(4) ? Fire Safety (Fire Extinguisher Instruction Upon Employment)
Date of Inspection: April 8-10, 2026
1. Statement of the Deficiency
A review of personnel records revealed the facility failed to ensure staff were instructed in the use of fire extinguishers upon employment in twenty-two of thirty-one applicable records reviewed. Specifically, staff either completed the training months after their hire date, or the documentation placed in their personnel file lacked an exact date or certificate to verify the timing of the training, listing only the year "2025" or "2026."
This is a repeat citation from the May 1, 2024 and April 25, 2025 annual licensing renewal inspections.
2. Corrective Action(s) Taken & Planned
Acknowledging that this is a multi-year repeat citation related to the onboarding process, Beacon Point Recovery Center has restructured New Hire Orientation to ensure compliance:
Immediate File Remediation:
The cited staff will undergo documented mandatory fire extinguisher re-training. Completion certificates for this training will include the exact month, day, and year of completion, along with the instructor's signature, to correct the ambiguous dates in the current personnel files.
New Hire Orientation Revision:
The facility's onboarding policy has been amended. Fire extinguisher instruction and fire-safety walkthroughs are now categorized as a Day One orientation requirement. No newly hired staff member, regardless of position, is permitted to begin shadowing or working on the floor until this module is completed and documented.
Standardized Dated Certificates:
The Human Resources Department will no longer accept sign-in sheets or training documentation that lists only the year of completion. A standardized Fire Safety and Extinguisher Competency Certificate has been created. This form requires the exact date of training, the staff member's hire date, and signatures from both the staff member and instructor.
3. Plan for Monitoring and Quality Assurance
To ensure this repeat citation is resolved and does not recur, the following auditing processes are now in effect:
New Hire Clearance Checklist:
The Human Resources Department will use a New Hire Clearance Checklist before any newly hired staff member is approved to begin work. If the exactly dated Fire Safety and Extinguisher Competency Certificate is missing from the orientation packet, the staff member will not be cleared to work until the requirement is completed and documented.
30-Day Compliance Audit:
Any missing, incomplete, or undated documentation will be immediately returned to the Human Resources Department and appropriate department leadership for correction before the staff member continues in active work status.
4. Title of Person Responsible for Implementation
Director of Compliance
With collaborative execution by the Human Resources Department
5. Target Completion Date
Re-training of Cited Staff: On or before June 21, 2026.
Full Compliance Reached: June 21, 2026. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's April 2025 through March 2026 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
At the time of the inspection, there was no documentation provided indicating a fire drill was completed during the months of April through July 2025, September through December 2025, and January through March 2026. The only fire drill documented was conducted during August 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 705.10 ? Fire safety (Fire Drills)
Date of Inspection: April 8-10, 2026
1. Statement of the Deficiency
A review of the facility's fire drill logs from April 2025 through March 2026 revealed a failure to conduct unannounced fire drills at least once a month. Documentation was entirely missing for April through July 2025, September through December 2025, and January through March 2026. Only one drill (August 2025) was documented during the 12-month review period.
2. Corrective Action(s) Taken & Planned
Missing 11 out of 12 required fire drills represents a severe breakdown in life-safety protocols during the facility's transitional period. To correct this immediately and build a resilient, failsafe scheduling system moving forward, Beacon Point has implemented the following actions:
Immediate Baseline Drill: An unannounced, facility-wide fire drill was conducted immediately following the inspection to ensure current staff and patients possess baseline evacuation competency.
Annual Master Schedule Creation: The Director of Compliance has developed a rolling, 12-month Master Fire Drill Schedule. To maintain the "unannounced" regulatory requirement while ensuring execution, this schedule dictates the specific week and shift (rotating through 1st, 2nd, and 3rd shifts) that a drill must occur, but keeps the exact day and time strictly confidential to the administrative team.
Standardized Documentation: The facility has instituted a new, standardized Fire Drill Evaluation Form. This form requires documentation of the date, exact time, shift, weather conditions, total evacuation time, and any operational barriers encountered (e.g., blocked exits, alarm audibility issues).
3. Plan for Monitoring and Quality Assurance (Audit Process)
To guarantee a drill is never missed again, the following strict auditing process has been established:
Corrective Execution: If the audit reveals a drill has not yet been conducted for that month, the Director of Compliance possesses the immediate authority to trigger an unannounced drill that same day to ensure zero lapse in monthly compliance.
4. Title of Person Responsible for Implementation
Director of Compliance
(With collaborative execution by the Facilities Manager and Shift Supervisors)
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
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 twenty-two of thirty-one applicable personnel records reviewed.
Employee #5 was hired as a counselor on September 17, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #6 was hired as a counselor on September 9, 2025. There was documentation of the completion of an emergency preparedness training; however, the training was not completed until January 8, 2026.
Employee #7 was hired as a counselor on February 24, 2026. There was documentation of the completion of an emergency preparedness training; however, the training was not completed until March 17, 2026.
Employee #9 was hired as a counselor on October 27, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #19 was hired as a behavioral health technician on September 26, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #21 was hired as a behavioral health technician on April 9, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #22 was hired as a behavioral health technician on August 11, 2025. There was documentation of the completion of an emergency preparedness training; however, the training was not completed until December 4, 2025.
Employee #23 was hired as a behavioral health technician on May 12, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #25 was hired as a behavioral health technician on November 3, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #26 was hired as a behavioral health technician on September 30, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #27 was hired as a behavioral health technician on July 25, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #28 was hired as a behavioral health technician on December 12, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #30 was hired as a behavioral health technician on January 19, 2026. There was documentation of the completion of an emergency preparedness training in 2026; however, there was no exact date or training certificate to verify when the training was completed.
Employee #31 was hired as a behavioral health technician on March 25, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #32 was hired as a behavioral health technician on February 20, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #33 was hired as a behavioral health technician on March 12, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #34 was hired as a behavioral health technician on February 11, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #35 was hired as a behavioral health technician on February 10, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #36 was hired as a behavioral health technician on February 18, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #37 was hired as a behavioral health technician on March 4, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
Employee #38 was hired as a behavioral health technician on February 11, 2026. There was documentation of the completion of an emergency preparedness training in 2026; however, there was no exact date or training certificate to verify when the training was completed.
Employee #42 was hired as a behavioral health technician on September 28, 2025. There was documentation of the completion of an emergency preparedness training in 2025; however, there was no exact date or training certificate to verify when the training was completed.
This is a repeat citation from the May 1, 2024 and April 25, 2025 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 705.10(d)(3) ? Fire safety (Emergency Task Training)
Date of Inspection: April 8-10, 2026
1. Statement of the Deficiency
A review of personnel records revealed the facility failed to ensure that all personnel, across all shifts, were trained to perform their assigned tasks during emergencies upon employment. In twenty-two of thirty-one applicable records reviewed, the emergency preparedness training was either completed months after the employee's hire date (Employees #6, #7, #22), or the documentation lacked an exact date or valid certificate, listing only the year "2025" or "2026" (Employees #5, #9, #19, #21, #23, #25, #26, #27, #28, #30, #31, #32, #33, #34, #35, #36, #37, #38, #42). This is a repeat citation from the May 1, 2024, and April 25, 2025, annual licensing renewal inspections.
2. Corrective Action(s) Taken & Planned
Because this deficiency is structurally identical to the fire extinguisher instruction citation and represents a multi-year failure in the facility's onboarding pipeline, Beacon Point has instituted a comprehensive overhaul of its orientation and documentation practices:
Immediate File Remediation: The twenty-two cited employees will be required to attend a mandatory Emergency Preparedness & Evacuation Protocol re-training in-service. This session will specifically outline the assigned emergency tasks for their respective shifts. The new completion certificates will include the exact month, day, and year, along with the instructor's signature, to replace the ambiguous documentation in their current files.
New Hire Orientation (NHO) Overhaul ("Day One" Mandate): The facility's onboarding policy has been formally amended. Emergency Preparedness Training?including specific instruction on assigned roles during a fire, medical emergency, or evacuation?is now strictly categorized as a "Day One" orientation requirement. No newly hired employee is permitted to begin working on the floor until this module is completed and verified.
3. Plan for Monitoring and Quality Assurance (Audit Process)
To ensure this repeat citation is permanently resolved, the following "hard-stop" auditing processes are now in effect:
30-Day Compliance Audit: The Director of Compliance will audit 100% of all new hire personnel files within 30 days of their start date to physically verify that the date on the Emergency Preparedness certificate matches the employee's first week of employment.
QAPI Integration: The Director of Compliance will report the findings of the new hire file audits to the Quality Assurance and Performance Improvement (QAPI) committee quarterly. Any failure by HR or department heads to secure this documentation on Day One will be treated as an immediate, severe performance issue.
4. Title of Person Responsible for Implementation
Director of Compliance
(With collaborative execution by the Human Resources Department)
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's April 2025 through March 2026 fire drill logs, the facility failed to maintain a fire drill record, which is to include the date, time, the amount of time it took for evacuation, the exit route used, the number of people in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
At the time of the inspection, the sole fire drill log completed at the time of the August 2025 fire drill did not include documentation of the number of people in the facility at the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 705.10 ? Fire safety (Fire Drills)
Date of Inspection: April 8-10, 2026
1. Statement of the Deficiency
A review of the facility's fire drill logs from April 2025 through March 2026 revealed a failure to conduct unannounced fire drills at least once a month. Documentation was entirely missing for April through July 2025, September through December 2025, and January through March 2026. Only one drill (August 2025) was documented during the 12-month review period.
2. Corrective Action(s) Taken & Planned
Missing 11 out of 12 required fire drills represents a severe breakdown in life-safety protocols during the facility's transitional period. To correct this immediately and build a resilient, failsafe scheduling system moving forward, Beacon Point has implemented the following actions:
Immediate Baseline Drill: An unannounced, facility-wide fire drill was conducted immediately following the inspection to ensure current staff and patients possess baseline evacuation competency.
Annual Master Schedule Creation: The Director of Compliance has developed a rolling, 12-month Master Fire Drill Schedule. To maintain the "unannounced" regulatory requirement while ensuring execution, this schedule dictates the specific week and shift (rotating through 1st, 2nd, and 3rd shifts) that a drill must occur, but keeps the exact day and time strictly confidential to the administrative team.
Standardized Documentation: The facility has instituted a new, standardized Fire Drill Evaluation Form. This form requires documentation of the date, exact time, shift, weather conditions, total evacuation time, and any operational barriers encountered (e.g., blocked exits, alarm audibility issues).
Digital Accountability Alerts: Calendar alerts have been programmed into the facility's administrative management system. On the first of every month, an automated notification is sent to the Facilities Manager and the Shift Supervisors, reminding them that an unannounced drill must be executed and logged before the month ends.
3. Plan for Monitoring and Quality Assurance (Audit Process)
To guarantee a drill is never missed again, the following strict auditing process has been established:
Corrective Execution: If the audit reveals a drill has not yet been conducted for that month, the Director of Compliance possesses the immediate authority to trigger an unannounced drill that same day to ensure zero lapse in monthly compliance.
4. Title of Person Responsible for Implementation
Director of Compliance
(With collaborative execution by the Facilities Manager and Shift Supervisors)
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility's April 2025 through March 2026 fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
As of the date of the inspection, there was no documentation provided showing indicating that a fire drill was conducted during sleeping hours for the entire period reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 705.10, Fire Safety, Sleeping Hours Fire Drills
Date of Inspection: April 8 to April 10, 2026
1. Statement of the Deficiency
A review of the facility's fire drill logs from April 2025 through March 2026 revealed a failure to conduct a fire drill during sleeping hours at least every six months. At the time of inspection, the facility could provide no documentation indicating that a sleeping hours, overnight/third-shift, fire drill was conducted at any point during the 12-month review period.
2. Corrective Action(s) Taken and Planned
Recognizing that overnight evacuations present unique life-safety challenges due to reduced staffing ratios and patient sleep states, Beacon Point Recovery Center has taken immediate action to ensure third-shift readiness and regulatory compliance.
Immediate Overnight Drill:
An unannounced sleeping-hours fire drill, occurring between the hours of 11:00 PM and 6:00 AM, was executed immediately following the citation. This drill tested the third-shift staff's ability to wake, rally, and safely evacuate the patient population.
Master Schedule Integration:
Building upon the corrective actions established for monthly drills, the Director of Compliance has explicitly incorporated the sleeping-hours drill requirement into the newly established 12-month Master Fire Drill Schedule. The schedule now mandates that a minimum of two unannounced drills per calendar year will be specifically assigned to the overnight shift, spaced no more than five months apart to ensure the six-month regulatory window is never missed.
Third-Shift In-Service:
All active overnight staff, including nursing staff and Behavioral Health Technicians, will undergo a targeted in-service regarding overnight evacuation protocols. This training will focus on room sweep procedures, waking and directing patients, safe evacuation during low-light conditions, and rapid deployment of roll-call rosters.
3. Plan for Monitoring and Quality Assurance
To ensure this biannual requirement is not overlooked, the following tracking systems have been implemented:
Targeted Digital Alerts:
The facility's administrative calendar has been programmed with a dedicated escalating alert system. This system will notify the Executive Director, Director of Compliance, and Third-Shift Supervisors 30 days prior to the deadline for the biannual sleeping-hours fire drill.
Monthly Log Verification:
During the Director of Compliance's end-of-month audit of the Life Safety and Drill Binder, the Director of Compliance will specifically cross-reference fire drill dates and shift times to track how many days have elapsed since the last third-shift fire drill.
4. Title of Person Responsible for Implementation
Director of Compliance
With collaborative execution by the Third-Shift Supervisors
5. Target Completion Date
Third-Shift Evacuation In-Service: On or before June 21, 2026.
Full Compliance Reached: June 21, 2026. |
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 years ending December 31, 2023 and December 31, 2024.
This is a repeat citation from the April 25, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 709.25, Fiscal Management, Annual Financial Audit
Date of Inspection: April 8 to April 10, 2026
1. Statement of the Deficiency
Based on an administrative review, the facility 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 and alcohol abuse services. This deficiency applies to the fiscal years ending December 31, 2023, and December 31, 2024.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center recognizes that annual financial audit completion is a required administrative and fiscal management responsibility. The facility has taken corrective action to ensure that required financial audits are completed, documented, maintained, and monitored going forward.
Independent Certified Public Accountant Engagement:
The facility's Governing Body has formally engaged an independent certified public accountant firm to complete the required annual financial audits for the fiscal years ending December 31, 2023, and December 31, 2024.
Completion of Outstanding Annual Financial Audits:
The independent certified public accountant firm will complete the outstanding annual financial audits for the fiscal years ending December 31, 2023, and December 31, 2024. Upon completion, the finalized audit reports will be reviewed by the Governing Body and maintained in the facility's administrative compliance records.
Ongoing Annual Audit Process:
To prevent future lapses, the facility has established an ongoing process requiring the annual financial audit to be initiated within 90 days after the close of each fiscal year. The facility will maintain written documentation of the certified public accountant engagement, audit initiation, audit progress, final audit report receipt, and Governing Body review.
Administrative Record Retention:
Completed financial audit reports, certified public accountant engagement letters, related correspondence, and documentation of Governing Body review will be maintained in the facility's centralized administrative compliance records and made available for review upon request.
3. Plan for Monitoring and Quality Assurance
To ensure continued compliance with annual financial audit requirements, the following monitoring process has been implemented:
Annual Compliance Calendar Reminder:
The Director of Compliance will maintain a recurring annual compliance calendar reminder each January to verify that the independent certified public accountant firm has been contacted and that the annual financial audit process has been initiated.
Quarterly Audit Status Review:
Until each annual financial audit is finalized, the Director of Compliance will review the status of the audit at least quarterly with the Executive Director and Governing Body to confirm progress, identify barriers, and ensure timely completion.
Annual Document Verification:
By May 1 of each calendar year, the Director of Compliance will audit the facility's administrative compliance records to verify that the final certified public accountant audit report for the prior fiscal year has been received, reviewed by the Governing Body, and filed.
Governing Body Oversight:
The Governing Body will maintain oversight of the annual financial audit process and will document review of completed audit reports in meeting minutes or other administrative records.
4. Title of Person Responsible for Implementation
Director of Compliance
Executive Director
Governing Body
5. Target Completion Date
Certified Public Accountant Firm Engagement Completed: On or before May 1, 2026
Completion of Outstanding 2023 and 2024 Annual
Full Compliance Reached: June 21, 2026 |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in two of sixteen client records reviewed.
Client #8 was admitted to the inpatient non-hospital activity on June 30, 2025 and was discharged on July 28, 2025. A release of information form to another treatment provider was signed and dated by the client on July 17, 2025; however, there was no documentation indicating a copy of the consent form was offered to the client.
Client #9 was admitted to the inpatient non-hospital activity on October 2, 2025 and was discharged on October 30, 2025. A release of information form to a government agency was signed and dated by the client on October 14, 2025; however, there was no documentation indicating a copy of the consent form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 709.28(d), Confidentiality, Client Consent Copy
Date of Inspection: April 8 to April 10, 2026
1. Statement of the Deficiency
Based on a review of client records, the facility failed to ensure documentation was maintained indicating that a copy of the consent to release information form was offered to the client in two of sixteen records reviewed. The records contained completed release of information forms; however, there was no documented evidence that the clients were offered a physical copy of their respective forms.
2. Corrective Action(s) Taken and Planned
Because the identified clients were discharged in 2025, retroactive documentation on those specific forms cannot be obtained. Beacon Point Recovery Center has implemented corrective actions to ensure that all future release of information forms include clear documentation that the client was offered a copy of the completed consent form.
Revision of Release of Information Form:
The facility's standardized Release of Information form has been revised to include a required acknowledgment section directly above the client signature line. The revised section states:
"I acknowledge that I have been offered a physical copy of this completed consent form."
This section includes mandatory options for the client to indicate whether the copy was accepted or declined, along with a required client initials field.
Electronic Medical Record Integration:
For electronically signed consents, the Electronic Medical Record system has been updated to require completion of the "Copy Offered/Provided" field before the form can be finalized and saved in the client record. This creates a documentation safeguard to prevent incomplete release of information forms from being entered into the record.
Staff Education:
Clinical staff, Health Information Management staff, and any staff responsible for obtaining release of information forms will receive education on the revised consent process. Education will include the requirement to offer the client a copy of the completed consent form, document whether the copy was accepted or declined, and ensure all required fields are completed before filing or saving the form.
3. Plan for Monitoring and Quality Assurance
To ensure this documentation standard is consistently maintained and to prevent recurrence, the following monitoring process has been established:
Weekly Release of Information Review:
The Health Information Management Coordinator will review 100% of newly executed Release of Information forms each week to verify that the copy offered section is completed, including the accepted or declined selection and required client initials. Any incomplete form will be flagged and returned to the appropriate staff member for correction with the client, when possible.
Monthly Compliance Audit:
The Director of Compliance will conduct a randomized monthly audit of 10% of active client records. This audit will review the consent and legal documentation sections of the record to verify compliance with 28 Pa. Code § 709.28(d).
Corrective Follow-Up:
If deficiencies are identified during weekly or monthly audits, the Director of Compliance will notify the applicable department supervisor. The issue will be corrected, staff re-education will be provided as needed, and repeated errors will be addressed through the facility's performance accountability process.
Documentation Retention:
Audit findings, corrective actions, and staff education records will be maintained in the facility's compliance records and made available for review upon request.
4. Title of Person Responsible for Implementation
Director of Compliance
Clinical Director
Applicable Department Supervisors
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the project failed to maintain a data collection and recordkeeping system that allowed for the efficient retrieval of data needed to measure the project's performance.
Leading up to and during the inspection, the facility was given multiple opportunities to submit the requested documentation required for the inspection to the Licensing Representative. The requested documentation was not provided leading up to the day of the inspection and during the inspection, the information was not provided in a timely manner. Additionally, on the day of the inspection, the facility took approximately two hours to give the Licensing Representative full and free access to their electronic medical record system.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
LAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 709.31(a), Data Collection System, Efficient Retrieval
Date of Inspection: April 8 to April 10, 2026
1. Statement of the Deficiency
Based on an administrative review, the facility failed to maintain a data collection and recordkeeping system that allowed for the efficient retrieval of data needed to measure the project's performance. Requested documentation was not submitted to the Licensing Representative prior to the inspection or in a timely manner during the inspection. Additionally, on the day of the inspection, the facility did not provide full and free access to the Electronic Medical Record system in a timely manner.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center acknowledges that documentation and Electronic Medical Record access must be organized, current, and immediately retrievable during licensing reviews. The facility has implemented corrective actions to ensure that requested documentation, compliance records, and Electronic Medical Record access can be provided efficiently and without delay.
Centralized Compliance Record System:
The facility has created a centralized electronic compliance record system for storage and retrieval of licensing-related documentation. This system includes organized folders for regulatory documents, personnel records, training records, fire safety documentation, physical plant records, client record audits, policies and procedures, governing body documentation, incident reporting, and other records needed to measure facility performance.
Master Document Index:
A Master Document Index has been developed to identify where required records are stored, the department responsible for maintaining each record, the expected update frequency, and the job title responsible for ensuring the document remains current. This index will be maintained in the centralized compliance record system.
Pre-Configured Surveyor Access:
A pre-configured surveyor access profile has been created within the Electronic Medical Record system. The profile is designed to allow full and free access to requested client records during licensing reviews while maintaining appropriate confidentiality and system security requirements.
Survey Readiness Protocol:
The facility has implemented a Survey Readiness Protocol that outlines the process for responding to licensing document requests. The protocol identifies responsible job titles, required response steps, backup personnel, and escalation procedures if requested documents or Electronic Medical Record access cannot be produced immediately.
Staff Education:
Leadership staff, Health Information Management staff, compliance staff, and applicable department supervisors will receive education on the Survey Readiness Protocol, centralized compliance record system, Master Document Index, and process for providing timely Electronic Medical Record access during inspections.
3. Plan for Monitoring and Quality Assurance
To ensure rapid retrieval of records and timely Electronic Medical Record access remain fully operational, the following monitoring process has been established:
Monthly Administrative Record Audit:
On the first business day of each month, the Director of Compliance will audit the centralized compliance record system to verify that required logs, reports, rosters, training records, fire safety records, physical plant records, and other compliance documents from the prior month have been uploaded, correctly filed, and are immediately retrievable.
Monthly Electronic Medical Record Access Verification:
The Director of Compliance, in collaboration with the Health Information Management Department, will verify monthly that the pre-configured surveyor access profile remains active, functional, and capable of providing appropriate access to client records during a licensing review.
Quarterly Mock Retrieval Drill:
The Director of Compliance will conduct a quarterly mock document retrieval drill. During this drill, selected documents from multiple departments will be requested and timed to confirm they can be located and produced promptly. Any delay, missing record, or access issue will be documented and corrected.
Corrective Follow-Up:
If audits or mock retrieval drills identify missing documents, incorrect filing, delayed retrieval, or Electronic Medical Record access issues, the Director of Compliance will assign corrective action to the applicable department supervisor. Completion of corrective action will be documented in the compliance records.
Leadership Review:
Results of monthly audits and quarterly retrieval drills will be reviewed with the Executive Director and applicable department heads to ensure continued accountability and sustained compliance.
4. Title of Person Responsible for Implementation
Director of Compliance
Executive Director
Health Information Management Department
Applicable Department Supervisors
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on an administrative review, the facility failed to maintain a recordkeeping system that allows for the identification of client's admissions and discharges within a specific time.
At the time of the inspection, the facility was unable to produce a discharged client list, with accurate admit and discharge dates, in an efficient manner as it took approximately two hours to generate the complete and accurate discharge list.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PPLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 709.31(b), Data Collection System, Admissions and Discharges
Date of Inspection: April 8 to April 10, 2026
1. Statement of the Deficiency
Based on an administrative review, the facility failed to maintain a recordkeeping system that allows for the efficient identification of client admissions and discharges within a specific timeframe. During the inspection, the facility was unable to produce a discharged client list with accurate admission and discharge dates in an efficient manner.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center recognizes that admission and discharge data must be accurate, current, and readily retrievable upon request. The facility has implemented corrective actions to ensure that client admission and discharge information can be generated efficiently, accurately, and consistently from the Electronic Medical Record system.
Standardized Admissions and Discharge Report:
The facility has created a standardized Electronic Medical Record report titled "DDAP Census and Discharge Summary." This report is designed to generate client admission and discharge data for any requested date range, including client name or identifier, admission date, discharge date, program level of care, and discharge status, as applicable.
Report Validation:
The Health Information Management Department will validate the report to ensure that admission dates, discharge dates, and discharge status fields are pulling correctly from the Electronic Medical Record system. Any data-mapping errors or missing fields will be corrected prior to final implementation.
Administrative Cross-Training:
The Director of Compliance will ensure that designated staff by job title, including Health Information Management staff, admissions staff, compliance staff, and applicable administrative supervisors, are trained to generate the standardized admissions and discharge report. This will ensure that the facility is not dependent on one staff member to retrieve required data.
Written Retrieval Procedure:
A written procedure has been developed outlining how to generate an admissions and discharge list for any requested timeframe. The procedure includes step-by-step report instructions, responsible job titles, backup job titles, expected retrieval timeframe, and escalation steps if the report does not generate correctly.
Centralized Report Storage:
Weekly admissions and discharge reports will be saved in the centralized compliance record system to support rapid retrieval, trend review, and verification of record accuracy.
3. Plan for Monitoring and Quality Assurance
To ensure the admissions and discharge data retrieval system remains accurate and fully functional, the following monitoring process has been implemented:
Weekly Census Verification Audit:
Every Monday, the Health Information Management Coordinator will generate the "DDAP Census and Discharge Summary" report for the preceding week. This audit will verify that the report is functioning correctly and that admission and discharge data can be retrieved efficiently.
Monthly Accuracy Review:
The Director of Compliance, in collaboration with the Health Information Management Department and Admissions Department, will complete a monthly review of a sample of admissions and discharges to verify that the report matches the information documented in the Electronic Medical Record.
Quarterly Mock Survey Time Trial:
As part of the facility's quarterly mock survey readiness process, the Director of Compliance will request an admissions and discharge list for a randomized historical date range. Designated administrative staff must be able to generate and produce the accurate list within five minutes.
Corrective Follow-Up:
If the weekly audit, monthly review, or mock survey time trial identifies delayed retrieval, missing data, inaccurate admission or discharge dates, or report functionality issues, the Director of Compliance will assign corrective action to the applicable department supervisor. Completion of corrective action will be documented in the facility's compliance records.
Leadership Review:
Audit findings, report accuracy concerns, and corrective actions will be reviewed with the Executive Director and applicable department heads to ensure continued accountability and sustained compliance.
4. Title of Person Responsible for Implementation
Director of Compliance
Health Information Management Department
Admissions Director
Applicable Administrative Supervisors
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on an administrative review of the facility's reported unusual incident reports, the facility failed to follow their policy and procedures regarding the documentation of unusual incidents.
The facility's policy and procedures manual stated that within (24) hours of an incident, an unusual incident report form will be completed when any such applicable incident occurs. The form will be forwarded to a staff member's immediate supervisor as well as the Clinical Director and Director of Compliance. The Clinical Director will then initiate a prompt review and investigation of the incident including, if necessary, a departmental supervisor. A root cause analysis and corrective plan of action, when indicated, will be implemented in a timely and appropriate manner. The appropriate department head will monitor any corrective action plan to ensure ongoing compliance.
At the time of the inspection, facility staff were unable to provide their unusual incidents on unusual incident report forms, according to their policy and procedure. Facility staff did produce copies of 17 different email chains as documentation of their unusual incident reports.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 709.34(b)(1), Reporting of Unusual Incidents, Documentation
Date of Inspection: April 8 to April 10, 2026
1. Statement of the Deficiency
Based on an administrative review of the facility's unusual incident records, the facility failed to follow its own written policies and procedures regarding documentation of unusual incidents. The facility's policy requires completion of an official unusual incident report form within 24 hours, followed by formal review and root cause analysis. Instead, unusual incident documentation was maintained through email chains rather than the required unusual incident report form and review process.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center recognizes that unusual incidents must be documented using the approved reporting process to ensure timely review, root cause analysis, corrective action, and patient safety oversight. The facility has implemented corrective actions to ensure all unusual incidents are reported, documented, reviewed, and retained according to facility policy and regulatory requirements.
Centralized Unusual Incident Reporting Process:
The facility has implemented a centralized unusual incident reporting process requiring staff to complete the approved unusual incident report form for all reportable incidents. Email communication may be used for notification or follow-up only, but it will not replace the required unusual incident report form.
Digital Unusual Incident Report Form:
The unusual incident report form has been digitized and made accessible on facility computers and nursing stations. The digital form requires completion of required fields and routes the completed report to the appropriate supervisory and leadership job titles for review.
Historical Record Correction:
The facility will review the previously identified email chains and transcribe the available incident information onto the approved unusual incident report form when sufficient information is available. These completed forms will be retained with the facility's unusual incident records and clearly marked as historical record corrections.
Root Cause Analysis and Review Process:
Each completed unusual incident report form will be reviewed by the appropriate supervisory and clinical leadership job titles. When indicated, a root cause analysis will be completed, corrective actions will be assigned, and follow-up will be documented.
Staff Education:
All applicable staff will receive education on the unusual incident reporting policy, required use of the approved unusual incident report form, 24-hour documentation requirement, escalation process, and prohibition against using email chains as the official incident record.
3. Plan for Monitoring and Quality Assurance
To ensure unusual incident documentation is completed consistently and according to facility policy, the following monitoring process has been established:
Weekly Cross-Reference Audit:
Every Friday, the Director of Compliance will cross-reference the unusual incident report database against shift supervisor logs, clinical documentation, nursing notes, and other applicable operational records. If an incident is referenced but no official unusual incident report form was completed within the required timeframe, the matter will be escalated to the Executive Director and applicable department supervisor for immediate corrective action.
Monthly Incident Documentation Audit:
The Director of Compliance will conduct a monthly audit of unusual incident records to verify that required forms are complete, submitted within the required timeframe, reviewed by the appropriate leadership job titles, and include root cause analysis and corrective action when applicable.
Corrective Follow-Up:
Any missing, late, incomplete, or improperly documented unusual incident report will result in immediate staff re-education and supervisory follow-up. Repeated noncompliance will be addressed through the facility's performance accountability process.
Leadership Review:
Unusual incident reporting trends, audit findings, root cause analysis results, and corrective actions will be reviewed by the Executive Director, Director of Compliance, Clinical Director, and applicable department heads to ensure sustained compliance and patient safety improvement.
Documentation Retention:
Completed unusual incident report forms, root cause analyses, corrective actions, staff education records, and audit results will be maintained in the facility's compliance records and made available for review upon request.
4. Title of Person Responsible for Implementation
Director of Compliance
Clinical Director
Executive Director
Applicable Department Supervisors
5. Target Completion Date
Historical Incident Record Correction Completed: On or before April 30, 2026
Digital Incident Report Form and Staff Directive Implemented: On or before May 15, 2026
Staff Education and Incident Review Process Fully Implemented: On or before June 21, 2026
Full Compliance Reached: June 21, 2026 |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire or ambulance personnel.
On March 13, 2026, emergency medical personnel were called to the facility; however, the incident was not reported to the Department 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
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 709.34(c)(4), Reporting of Unusual Incidents, Notification to Department
Date of Inspection: April 8 to April 10, 2026
1. Statement of the Deficiency
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire, or ambulance personnel. Emergency medical personnel were dispatched to the facility; however, the event was not reported to the Department prior to the licensing inspection.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center recognizes that any event requiring the presence of police, fire, or ambulance personnel must be reviewed immediately to determine whether notification to the Department is required within 3 business days. The facility has implemented corrective actions to ensure that emergency responses are identified, escalated, reviewed, and reported within the required timeframe.
Immediate Emergency Response Notification Protocol:
The facility has implemented a protocol requiring the Charge Nurse or Shift Supervisor to immediately notify the on-call administrator by phone any time 911 is called or police, fire, or ambulance personnel respond to the facility. This immediate notification process is intended to ensure leadership is aware of the event as soon as it occurs and that the 3-business-day reporting requirement is tracked without delay.
Unusual Incident Reporting Review:
All emergency responses involving police, fire, or ambulance personnel will be reviewed by the Director of Compliance, Utilization Review Department, and applicable leadership staff to determine whether the incident meets Department reporting requirements. This review will occur promptly after notification and will be documented.
Department Notification Process:
When an incident meets the criteria for Department notification, the Director of Compliance, or designee by job title, will ensure the required report is submitted to the Department within 3 business days. Documentation of submission will be maintained in the unusual incident reporting file.
Integration with Existing Serious Incident Review Process:
The facility will incorporate Department-reportable unusual incident review into the existing serious incident review workflow used by the Utilization Review Department. This will create an additional review layer to ensure that emergency responses are not missed and that all required external notifications are completed.
Staff Education:
Nursing staff, Behavioral Health Technicians, Shift Supervisors, Utilization Review staff, and applicable department supervisors will receive education on the requirement to immediately report any 911 call or emergency personnel response to the facility. Education will include the 3-business-day Department notification requirement, internal escalation process, documentation expectations, and responsible job titles.
3. Plan for Monitoring and Quality Assurance
To ensure emergency responses are consistently identified and reported when required, the following monitoring process has been implemented:
Daily Emergency Response Review:
The Charge Nurse or Shift Supervisor will document any 911 call or emergency personnel response in the shift report and notify the on-call administrator immediately. The Director of Compliance or designee will review shift reports each business day to identify any event involving police, fire, or ambulance personnel.
Utilization Review Cross-Check:
The Utilization Review Department will review emergency responses as part of the facility's serious incident review process. This review will confirm whether the incident requires Department notification and whether submission was completed within the required 3-business-day timeframe.
Weekly Unusual Incident Audit:
The Director of Compliance will conduct a weekly audit comparing shift reports, nursing documentation, unusual incident reports, ambulance call records when available, and serious incident review logs. Any emergency response without a corresponding unusual incident review and reporting determination will be escalated for immediate correction.
Corrective Follow-Up:
If an event requiring Department notification is not reported within the required timeframe, the Director of Compliance will notify the Executive Director and applicable department supervisor. Corrective action will include immediate submission when applicable, staff re-education, and documented supervisory follow-up.
Documentation Retention:
The facility will maintain documentation of emergency response notifications, reporting determinations, Department submissions, serious incident reviews, audit findings, and corrective actions in the unusual incident reporting file.
4. Title of Person Responsible for Implementation
Director of Compliance
Director of Nursing
Utilization Review Department
Shift Supervisors
Applicable Department Supervisors
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
709.63(a)(8) LICENSURE Follow-up Information
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of four applicable client records reviewed.
Client #4 was admitted to the inpatient detoxification activity on July 15, 2025 and was discharged on July 21, 2025. There was no documentation of follow-up information in the client record as of the date of the inspection.
Client #6 was admitted to the inpatient detoxification activity on November 19, 2025 and was discharged on November 22, 2025. There was no documentation of follow-up information in the client record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 709.63(a)(8) ? Client Records (Follow-up Information)
Date of Inspection: April 8-10, 2026
1. Statement of the Deficiency
A review of client records revealed that the facility failed to maintain a complete client record inclusive of documented follow-up information in two of four applicable records reviewed. Specifically, two inpatient detoxification client records did not contain documentation of post-discharge follow-up information at the time of the inspection.
2. Corrective Action(s) Taken & Planned
Ensuring patients successfully transition from inpatient detoxification to the next level of care is critical to clinical continuity, discharge planning, and long-term recovery outcomes. To correct this documentation gap and systematize aftercare tracking, Beacon Point Recovery Center has implemented the following action:
Departmental In-Service:
All clinical staff and case management staff have been retrained on the regulatory requirement to maintain complete client records, including documentation of follow-up information. The training specifically outlined how to properly complete and document post-discharge follow-up information in the electronic medical record follow-up task queue.
3. Plan for Monitoring and Quality Assurance
To ensure follow-up information is consistently captured and filed before a chart is permanently closed, the following auditing processes have been established:
Weekly Health Information Management Discharge Audit:
The Health Information Management Coordinator will run a weekly Pending Follow-Up report. Any discharged chart that reaches day 10 post-discharge without a documented follow-up note will be immediately flagged and escalated to the Clinical Director for same-day correction by the assigned staff member.
Monthly Compliance Audit:
The Director of Compliance will conduct a randomized audit of 10% of closed charts each month, specifically targeting the aftercare and follow-up sections to verify adherence to the electronic medical record follow-up protocol.
Any missing or incomplete follow-up documentation will be documented on the audit tool, returned to the appropriate department leadership for correction, and tracked until resolved.
4. Title of Person Responsible for Implementation
Director of Compliance
With collaborative execution by the Clinical Director and Case Management Department
5. Target Completion Date
Full Compliance Reached: June 21, 2026. |
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 ensure proper verification of the individual's identity, which is to include name, address, date of birth, emergency contact, and other identifying data in one of nine applicable patient records reviewed.
Patient #4 was admitted to the inpatient non-hospital detoxification activity on July 15, 2025 and was discharged on July 21, 2025. There was an identification attestation form documented in the patient record; however, the form was not completed and there was no other identification for the patient in the record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 709.x, Client Records, Identity Verification
Date of Inspection: April 8 to April 10, 2026
1. Statement of the Deficiency
Based on a review of client records, the facility failed to ensure proper verification of the individual's identity, including name, address, date of birth, and emergency contact information, in one of nine applicable records reviewed. The record contained a blank, incomplete identification attestation form, and no alternative identification documents were present in the record.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center recognizes that proper identity verification is required to support client safety, accurate recordkeeping, emergency contact accuracy, billing integrity, and regulatory compliance. The facility has implemented corrective actions to ensure that identity verification is completed, documented, and reviewed for all admissions.
Admissions Workflow Update:
The admissions workflow has been updated to require verification of client identity during the admission process. Verification includes confirmation of the client's name, address, date of birth, and emergency contact information. If a client does not have identification documentation available, the identification attestation form must be completed in full and filed in the client record.
Electronic Medical Record Safeguard:
The Electronic Medical Record admission workflow has been reviewed and updated to require completion of identity verification documentation before the admission record can be finalized. This safeguard is intended to prevent blank or incomplete identity verification forms from remaining in the client record.
Daily Admissions Huddle:
The Admissions Director will conduct a daily structured admissions huddle with intake and clinical staff. During this huddle, intake staff will confirm that identity verification has been completed for all admissions from the previous 24 hours and that required documentation is present in the client record.
Admissions Staff Education:
All intake and admissions staff will receive education on the facility's identity verification policy, completion of the identification attestation form, required emergency contact verification, and use of the Electronic Medical Record safeguards.
3. Plan for Monitoring and Quality Assurance
To ensure that client records contain complete identity verification documentation moving forward, the following monitoring process has been implemented:
24-Hour Admissions Audit:
The Admissions Director will conduct a daily structured audit of all new admissions from the previous 24 hours. Any record missing verified identification documentation or a completed identification attestation form will be immediately flagged and corrected.
Monthly Compliance Spot Check:
The Director of Compliance will conduct a randomized monthly audit of 10% of active client records to verify that identity verification documentation is complete, accurate, and present in the record.
Corrective Follow-Up:
If missing or incomplete identity verification documentation is identified, the Director of Compliance will notify the Admissions Director and applicable department supervisor. Corrective action will include immediate completion of missing documentation when possible, staff re-education, and documented supervisory follow-up.
Documentation Retention:
Completed identity verification documentation, attestation forms, audit results, corrective actions, and staff education records will be maintained in the appropriate client record or compliance file and made available for review upon request.
4. Title of Person Responsible for Implementation
Director of Compliance
Admissions Director
Intake Staff
Applicable Department Supervisors
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
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 ensure the narcotic treatment physician conducted the initial face-to-face determination with the client, prior to the administration of a maintenance agent, in one of nine applicable patient records reviewed.
Patient #16 was admitted to the inpatient non-hospital detoxification activity on August 27, 2025 and was discharged on September 1, 2025. The physician prescribed the patient's first dose of medication on August 29, 2025. The initial face-to-face determination with the physician was completed and documented in the record on September 9, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 715.9(a)(4), Intake, Physician Face to Face Determination
Date of Inspection: April 8 to April 10, 2026
1. Statement of the Deficiency
Based on a review of client records, the facility failed to ensure that a narcotic treatment physician conducted and documented an initial face to face determination of physiological dependence prior to the administration of a maintenance agent. The required physician face to face determination was not completed and documented in the client record prior to medication administration.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center recognizes that the initial face to face physician determination of physiological dependence must be completed and documented before the administration of a maintenance agent. The facility has implemented corrective actions to ensure that medication administration does not occur until the required physician determination is completed and documented in the client record.
Client Record Review and Remediation:
Because the identified client has been discharged, retroactive compliance cannot be achieved. The Medical Director reviewed the record to verify clinical appropriateness of the medication provided, and a late entry addendum was placed in the record acknowledging the documentation timing error.
Medical and Nursing Staff Education:
All applicable medical providers and nursing staff received education regarding the requirement that the narcotic treatment physician must complete and document the initial face to face determination of physiological dependence before the first dose of a maintenance agent is administered.
Medication Administration Safeguard:
The facility has implemented a safeguard requiring nursing staff to verify that the physician face to face determination is completed and documented in the client record before administering the initial dose of a maintenance agent. If the documentation is not present, nursing staff may not administer the initial dose and must immediately notify the Medical Director or covering narcotic treatment physician.
Electronic Medical Record Review:
The Electronic Medical Record workflow has been reviewed to ensure the physician face to face determination is clearly identifiable before medication administration. The facility will continue to evaluate opportunities to strengthen Electronic Medical Record prompts, required fields, or alerts to support compliance with the required sequence of care.
Clinical Leadership Oversight:
The Medical Director and Director of Nursing will ensure that the intake, prescribing, and medication administration workflow clearly requires physician determination before initial dose administration.
3. Plan for Monitoring and Quality Assurance
To ensure that the required physician determination is completed before medication administration, the following monitoring process has been implemented:
Daily New Admission Review:
The Director of Nursing, or designee by job title, will review all new narcotic treatment admissions each business day to verify that the physician face to face determination was completed and documented before the initial dose was administered.
Medication Administration Record Review:
The Director of Nursing, or designee by job title, will compare the physician determination documentation time and date with the initial medication administration time and date to confirm the required sequence was followed.
Monthly Compliance Spot Check:
The Director of Compliance will conduct a randomized monthly audit of 10% of new narcotic treatment admissions. The audit will review intake documentation and medication administration records to verify that the physician face to face determination was completed and documented before initial dose administration.
Immediate Corrective Action:
If an audit identifies that an initial dose was administered before the required physician determination was completed and documented, the Director of Compliance will immediately notify the Executive Director, Medical Director, and Director of Nursing. Corrective action will include immediate review of the record, staff reeducation, supervisory follow up, and review of whether additional reporting or corrective action is required.
Documentation Retention:
Audit results, corrective actions, staff education records, and verification of compliance will be maintained in the facility's compliance records and made available for review upon request.
4. Title of Person Responsible for Implementation
Medical Director
Director of Nursing
Director of Compliance
Nursing Staff
Applicable Medical Providers
5. Target Completion Date
Medical and Nursing Staff Education Completed: On or before June 21, 2026
Full Compliance Reached: June 21, 2026 |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to ensure the completion of an initial drug-screening analysis for each prospective patient in one of nine patient records reviewed.
Patient #16 was admitted to the inpatient non-hospital detoxification activity on August 27, 2025 and was discharged on September 1, 2025. The physician prescribed the patient's first dose of medication on August 29, 2025. The first urinalysis drug-screen, documented in the record, was completed on September 4, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 715.x, Intake, Initial Drug-Screening Analysis
Date of Inspection: April 8 to April 10, 2026
1. Statement of the Deficiency
Based on a review of client records, the facility failed to ensure completion of an initial drug-screening analysis for a prospective client prior to admission and administration of a maintenance agent. The required initial drug-screening analysis was not completed and documented in the client record prior to medication administration.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center recognizes that an initial drug-screening analysis is required prior to admission and before administration of a maintenance agent. The facility has implemented corrective actions to ensure that prospective clients receive required drug-screening analysis before medication administration occurs.
Intake Workflow Update:
The intake workflow has been revised to require completion and documentation of the initial drug-screening analysis before the client is admitted to narcotic treatment services and before any maintenance agent is administered.
Required Sequence of Care:
The facility has reinforced the required sequence for narcotic treatment intake as follows: triage, initial drug-screening analysis, physician face to face determination, medication order, and medication administration. Medication administration may not occur until the initial drug-screening analysis has been completed and documented.
Nursing and Intake Staff Education:
All applicable nursing staff and admissions staff have been retrained on the required intake sequence, including the requirement that the initial drug-screening analysis must be completed prior to admission and before administration of a maintenance agent.
Medication Administration Safeguard:
Nursing staff must verify that the initial drug-screening analysis has been completed and documented before administering the first dose of a maintenance agent. If the drug-screening analysis is not documented, nursing staff may not administer the medication and must immediately notify the Director of Nursing, Medical Director, or covering medical provider.
Laboratory Documentation Process:
The facility has implemented a process to ensure that point-of-care drug-screening results and confirmatory laboratory documentation, when applicable, are entered into the client record and available for review.
3. Plan for Monitoring and Quality Assurance
To ensure that required drug-screening analysis is completed prior to admission and medication administration, the following monitoring process has been implemented:
Daily New Admission Review:
The Director of Nursing, or designee by job title, will review all new narcotic treatment admissions each business day to verify that the initial drug-screening analysis was completed and documented before the first maintenance dose was administered.
Weekly Laboratory Reconciliation:
The Infection Control/Lab Nurse will reconcile point-of-care drug-screening results with confirmatory laboratory logs, when applicable, to verify that a drug-screening sample was collected, processed, and documented for each admitted client.
Monthly Compliance Spot Check:
The Director of Compliance will conduct a randomized monthly audit of 10% of new narcotic treatment admissions. This audit will compare intake documentation, drug-screening documentation, physician determination documentation, medication orders, and medication administration records to confirm the required sequence was followed.
QAPI Review:
Compliance with pre-admission drug-screening requirements will be tracked as a clinical quality metric and reviewed during quarterly Quality Assurance and Performance Improvement meetings. Identified trends, barriers, and corrective actions will be documented.
Immediate Corrective Action:
If an audit identifies that a maintenance agent was administered before completion and documentation of the initial drug-screening analysis, the Director of Compliance will notify the Executive Director, Director of Nursing, Medical Director, and applicable department supervisor. Corrective action will include immediate record review, staff re-education, supervisory follow-up, and evaluation of whether additional reporting or corrective action is required.
Documentation Retention:
Drug-screening documentation, laboratory reconciliation records, audit results, QAPI review documentation, corrective actions, and staff education records will be maintained in the client record or compliance file and made available for review upon request.
4. Title of Person Responsible for Implementation
Director of Nursing
Medical Director
Director of Compliance
Infection Control/Lab Nurse
Admissions Staff
Nursing Staff
Applicable Medical Providers
5. Target Completion Date
Medication Administration Safeguard Implemented: On or before June 21, 2026
Full Compliance Reached: June 21, 2026 |
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 the narcotic treatment physician determined the proper dosage level for a patient and 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 in three of nine applicable patient records reviewed.
Patient #4 was admitted to the inpatient non-hospital detoxification activity on July 15, 2025 and was discharged on July 21, 2025. The initial methadone dose for this patient was determined and ordered by a physician assistant, not a narcotic treatment physician. Also, there was no countersignature on the initial order by a narcotic treatment physician. Additionally, the initial physical examination was conducted by a different physician from the ordering physician assistant and there was no consultation documentation in the record prior to the patient's initial dose and schedule.
Patient #15 was admitted to the inpatient non-hospital detoxification activity on September 27, 2025 and was discharged on October 2, 2025. The initial physical examination was conducted by a different physician from the ordering physician and there was no consultation documentation in the record before determining the patient's initial dose and schedule.
Patient #16 was admitted to the inpatient non-hospital detoxification activity on August 27, 2025 and was discharged on September 1, 2025. The initial physical examination was conducted by a different physician from the ordering physician and there was no consultation documentation in the record before determining the patient's initial dose and schedule.
This is a repeat citation from the May 1, 2024 and April 25, 2025 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 715.15(b) ? Medication dosage (Physician Determination and Consultation)
Date of Inspection: April 8-10, 2026
1. Statement of the Deficiency
Based on a review of patient records, the facility failed to ensure a narcotic treatment physician determined the proper initial dosage level for a patient. Furthermore, when the prescribing physician was not the physician who conducted the initial physical examination, the facility failed to ensure and document a consultation between the two providers prior to determining the initial dose and schedule.
Specifically:
Patient #4: The initial methadone dose was ordered by a Physician Assistant (PA) without a physician countersignature. The initial exam was conducted by a different physician, and no consultation documentation was present.
Patient #15 & Patient #16: The initial physical examinations were conducted by different physicians than the ordering physicians, with no documented consultations in the records prior to the initial dose.
This is a severe, systemic repeat citation from the May 1, 2024, and April 25, 2025, annual licensing renewal inspections.
2. Corrective Action(s) Taken & Planned
Allowing mid-level providers (PAs) to independently order initial narcotic treatment doses without physician authorization, and failing to document cross-provider consultations, represents a critical breakdown in medical oversight. To permanently correct this three-year repeat deficiency, the new Medical Director has completely restructured the induction workflow:
Mandatory Medical Staff In-Service: The Medical Director held an emergency, mandatory in-service for all credentialed medical staff (MDs, DOs, PAs, NPs). The training explicitly covered the updated bylaws, the absolute prohibition on PA initial inductions, and the EMR consultation workflow.
3. Plan for Monitoring and Quality Assurance (Audit Process)
To ensure this repeat citation is permanently eradicated, the following rigorous medical auditing processes have been implemented:
4. Title of Person Responsible for Implementation
Medical Director
(With collaborative enforcement by the Director of Nursing and Nicholas Kline, Director of Compliance)
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure patient files, which includes admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, were transferred to the receiving narcotic treatment program in three of three applicable patient records reviewed.
Patient #8 was admitted to the inpatient non-hospital activity on June 30, 2025 and was transferred out on July 28, 2025. There was no documentation in the patient record indicating the receiving narcotic treatment program was provided with the required patient files.
Patient #9 was admitted to the inpatient non-hospital activity on October 2, 2025 and was transferred out on October 30, 2025. There was no documentation in the patient record indicating the receiving narcotic treatment program was provided with the required patient files.
Patient #10 was admitted to the inpatient non-hospital activity on September 1, 2025 and was transferred out on October 2, 2025. There was no documentation in the patient record indicating the receiving narcotic treatment program was provided with the required patient files.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 715.20(1), Patient Transfers, Narcotic Treatment Program File Transfer Protocol
Date of Inspection: April 2026
1. Statement of the Deficiency
Based on a review of client records, the facility failed to ensure that required client files were transferred to the receiving Narcotic Treatment Program in three of three applicable records reviewed. The records did not contain documentation verifying that the receiving facilities were provided with the required transfer information, including admission dates, medical and psychosocial summaries, dosage levels, urinalysis reports, exception requests, current status, and written consent.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center recognizes that complete and timely transfer of clinical, medical, and dosing information between Narcotic Treatment Programs is necessary to support continuity of care, medication safety, and regulatory compliance. The facility has implemented corrective actions to ensure that all required transfer documentation is completed, transmitted, and retained in the client record.
Standardized Narcotic Treatment Program Transfer Packet:
The facility has developed a standardized Narcotic Treatment Program transfer packet and checklist. The checklist includes all required elements under 28 Pa. Code § 715.20(1), including admission date, medical summary, psychosocial summary, dosage level, urinalysis reports, exception requests, current status, and written consent for release of information.
Transfer Documentation Requirement:
For all transfers to an external Narcotic Treatment Program, staff must complete the standardized transfer packet and document transmission to the receiving program. Verbal communication alone is not sufficient to meet the transfer documentation requirement. Proof of transmission, such as fax confirmation, secure email confirmation, electronic transmission receipt, or receiving program acknowledgment, must be retained in the client record.
Written Transfer Procedure:
The facility has implemented a written procedure outlining the steps for preparing, reviewing, transmitting, and filing the Narcotic Treatment Program transfer packet. The procedure identifies responsible job titles, required documentation, required consent, acceptable transmission methods, and required proof of transmission.
Staff Education:
Counseling staff, case management staff, Health Information Management staff, admissions staff, nursing staff, and applicable department supervisors will receive education on the updated Narcotic Treatment Program transfer process. Education will include completion of the standardized transfer packet, written consent requirements, transmission documentation, and the requirement that the transfer packet and proof of transmission be filed before chart closure.
3. Plan for Monitoring and Quality Assurance
To ensure complete file transfers are consistently documented moving forward, the following monitoring process has been implemented:
Real-Time Transfer Audit:
The Admissions Director, or designee by job title, will review 100% of Narcotic Treatment Program transfers within 48 hours of discharge or transfer. The review will verify that the standardized transfer packet was completed, required written consent was present, the required documents were transmitted to the receiving Narcotic Treatment Program, and proof of transmission was filed in the client record.
Monthly Closed Chart Audit:
The Director of Compliance will conduct a monthly randomized audit of closed client records, specifically targeting clients transferred to external Narcotic Treatment Programs. The audit will verify that required transfer documentation, written consent, and proof of transmission are complete and retained in the record.
Corrective Follow-Up:
If a transfer packet is incomplete, missing, not transmitted, or lacks proof of transmission, the Director of Compliance will notify the applicable department supervisor and Executive Director. Corrective action will include immediate completion or remediation when possible, staff re-education, and documented supervisory follow-up.
QAPI Review:
Narcotic Treatment Program transfer compliance will be tracked as a quality metric and reviewed during quarterly Quality Assurance and Performance Improvement meetings. Trends, barriers, corrective actions, and sustained compliance will be documented.
Documentation Retention:
Completed transfer packets, written consents, proof of transmission, receiving program acknowledgments, audit results, corrective actions, and staff education records will be maintained in the client record or compliance file and made available for review upon request.
4. Title of Person Responsible for Implementation
Director of Compliance
Admissions Director
Health Information Management Department
Executive Director
Director of Nursing
Applicable Department Supervisors
5. Target Completion Date
Standardized Narcotic Treatment Program Transfer Packet Implemented: On or before June 21, 2026
Staff Education Completed: On or before June 21, 2026
Full Compliance Reached: June 21, 2026 |
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 ensure that it notified the transferring narcotic treatment program, in writing, of the date of the admission and the date of the initial dose given to the patient upon transferring into the narcotic treatment program in two of three applicable patient records reviewed.
Patient #5 was transferred in and admitted to the inpatient non-hospital detoxification activity on June 25, 2025 and was discharged on June 30, 2025. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
Patient #15 was transferred in and admitted to the inpatient non-hospital detoxification activity on September 27, 2025 and was discharged on October 2, 2025. There was no documentation in the record indicating the transferring narcotic treatment program was notified of the date of admission and the date of the initial dose given.
This is a repeat citation from the April 25, 2025 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 715.20, Patient Transfers, Notification to Transferring Narcotic Treatment Program
Date of Inspection: April 2026
1. Statement of the Deficiency
Based on a review of client records, the facility failed to ensure that the transferring Narcotic Treatment Program was notified in writing of the client's date of admission and the date of the initial dose given upon transfer into the facility. The applicable records did not contain documentation confirming that written notification was sent to the transferring Narcotic Treatment Program. The facility acknowledges that this deficiency represents a failure to consistently complete and retain required transfer-in documentation.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center recognizes that written notification to the transferring Narcotic Treatment Program is required to support continuity of care, medication safety, and regulatory compliance. The facility has implemented corrective actions to ensure that all transfer-in admissions include written notification to the transferring program and that proof of notification is maintained in the client record.
Transfer-In Notification Procedure:
The facility has implemented a written transfer-in procedure requiring written notification to the transferring Narcotic Treatment Program of the client's admission date and initial dose date. This notification must be completed and documented for all clients transferring into the facility from another Narcotic Treatment Program.
Standardized Transfer-In Notification Form:
A standardized transfer-in notification form has been developed. The form includes the client's admission date, initial dose date, receiving program information, transferring program information, staff job title completing the notification, date sent, method of transmission, and confirmation that proof of transmission was filed in the client record.
Proof of Transmission Requirement:
Written notification must be sent by an approved method, such as secure fax, secure email, or other approved electronic transmission. Proof of transmission, including fax confirmation, secure email receipt, electronic transmission confirmation, or written acknowledgment from the transferring program, must be retained in the client record.
Electronic Medical Record Safeguard:
The Electronic Medical Record workflow has been reviewed and updated to include a required transfer-in notification step. The client transfer-in record may not be considered complete until the written notification and proof of transmission are uploaded or otherwise documented in the record.
Staff Education:
Admissions staff, nursing staff, Health Information Management staff, compliance staff, and applicable department supervisors will receive education on the transfer-in notification procedure. Education will include the requirement for written notification, required notification content, approved transmission methods, proof of transmission requirements, and documentation expectations.
Performance Accountability:
Compliance with transfer-in documentation requirements will be reviewed through routine supervision and department-level performance accountability. Repeated failure to complete required documentation will be addressed through the facility's corrective action and performance improvement process.
3. Plan for Monitoring and Quality Assurance
To ensure this deficiency does not recur, the following monitoring process has been implemented:
Daily Transfer-In Audit:
The Admissions Director, or designee by job title, will conduct a daily audit of all Narcotic Treatment Program transfer-in admissions from the previous 24 to 48 hours. This audit will verify that written notification was sent to the transferring Narcotic Treatment Program, that the admission date and initial dose date were included, and that proof of transmission was filed in the client record.
Weekly Compliance Verification:
The Director of Compliance will cross-reference the daily admissions log with the Electronic Medical Record document repository each week to confirm that all transfer-in clients have the required written notification and proof of transmission documented.
Monthly Closed and Active Chart Audit:
The Director of Compliance will conduct a monthly audit of active and closed client records involving transfer-in admissions to verify sustained compliance with the written notification requirement.
Corrective Follow-Up:
If a transfer-in notification is missing, incomplete, not transmitted, or lacks proof of transmission, the Director of Compliance will notify the Admissions Director and applicable department supervisor. Corrective action will include immediate remediation when possible, staff re-education, supervisory follow-up, and documentation of the corrective action taken.
QAPI Review:
Transfer-in notification compliance will be tracked as a quality metric and reviewed during quarterly Quality Assurance and Performance Improvement meetings. Trends, barriers, corrective actions, and sustained compliance will be documented.
Documentation Retention:
Transfer-in notification forms, proof of transmission, audit results, corrective actions, staff education records, and QAPI documentation will be maintained in the client record or facility compliance file and made available for review upon request.
4. Title of Person Responsible for Implementation
Director of Compliance
Admissions Director
Director of Nursing
Health Information Management Department
Admissions Staff
Nursing Staff
Applicable Department Supervisors
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in three of eight client records reviewed.
Client #10 was admitted to the inpatient non-hospital activity on September 1, 2025 and was discharged on October 2, 2025. There was no documentation of follow-up information in the client record as of the date of the inspection.
Client #13 was admitted to the inpatient non-hospital activity on April 27, 2025 and was discharged on May 27, 2025. There was no documentation of follow-up information in the client record as of the date of the inspection.
Client #14 was admitted to the inpatient non-hospital activity on December 5, 2025 and was discharged on February 10, 2026. There was no documentation of follow-up information in the client record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: 28 Pa. Code § 709.39, Client Records, Documentation of Follow-Up Information
Date of Inspection: Spring 2026
1. Statement of the Deficiency
Based on a review of client records, the facility failed to maintain complete client records inclusive of documented follow-up information in three of eight applicable records reviewed. The applicable records did not contain documentation of post-discharge follow-up information at the time of inspection.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center recognizes that post-discharge follow-up documentation is required to support continuity of care, aftercare engagement, documentation quality, and regulatory compliance. The facility has implemented corrective actions to ensure follow-up outreach is completed, documented, reviewed, and maintained in the client record.
Standardized Follow-Up Protocol:
The facility has formalized a standardized post-discharge follow-up protocol. Effective immediately, case management staff are required to conduct and document a minimum of two follow-up outreach attempts following discharge from the inpatient level of care. Follow-up attempts will occur at approximately 72 hours and 7 days post-discharge, unless otherwise clinically indicated or not possible.
Electronic Medical Record Follow-Up Task Queue:
The Electronic Medical Record workflow has been updated to generate a post-discharge follow-up task for case management staff following discharge. The task must be completed or documented as attempted before the chart is considered ready for final closure.
Follow-Up Documentation Requirements:
Follow-up documentation must include the date and time of the outreach attempt, method of outreach, staff job title completing the outreach, whether contact was successful or unsuccessful, client response when applicable, barriers identified, referrals or aftercare support provided, and any additional follow-up actions required.
Staff Education:
Clinical staff, case management staff, Health Information Management staff, and applicable department supervisors will receive education on the post-discharge follow-up protocol, documentation requirements, Electronic Medical Record task queue, and expectations for completing follow-up documentation before chart closure.
3. Plan for Monitoring and Quality Assurance
To ensure follow-up information is consistently captured and filed before a chart is permanently closed, the following monitoring process has been implemented:
Weekly Discharge Follow-Up Review:
The Clinical Director, or designee by job title, will review discharges from the prior week to verify that required follow-up tasks were generated and that follow-up outreach was completed or documented as attempted.
Monthly Closed Chart Audit:
The Director of Compliance will conduct a randomized monthly audit of 10% of closed client records, specifically reviewing the aftercare and follow-up sections to verify that required post-discharge follow-up documentation is present and complete.
Corrective Follow-Up:
If follow-up documentation is missing, incomplete, or not completed within the expected timeframe, the Director of Compliance will notify the Clinical Director and applicable department supervisor. Corrective action will include completion of follow-up documentation when possible, staff re-education, and documented supervisory follow-up.
QAPI Review:
Post-discharge follow-up compliance will be tracked as a quality metric and reviewed during quarterly Quality Assurance and Performance Improvement meetings. Trends, barriers, corrective actions, and sustained compliance will be documented.
Documentation Retention:
Follow-up outreach documentation, audit results, corrective actions, staff education records, and QAPI review documentation will be maintained in the client record or compliance file and made available for review upon request.
4. Title of Person Responsible for Implementation
Director of Compliance
Clinical Director
Case Management Department
Health Information Management Department
Applicable Department Supervisors
5. Target Completion Date
Full Compliance Reached: June 21, 2026 |
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 ensuring all staff complete fire extinguisher training upon employment was submitted and approved by the Department for the May 1, 2024 and April 25, 2025, annual licensing inspections. Failing to complete fire extinguisher training upon employment was again found to be a deficiency in the April 7, 2026 through April 10, 2026, licensing inspection.
A plan of correction for ensuring all staff are trained to perform assigned tasks during emergencies was submitted and approved by the Department for the May 1, 2024 and April 25, 2025, annual licensing inspections. Failing to ensure all staff are trained to perform assigned tasks during emergencies was again found to be a deficiency in the April 7, 2026 through April 10, 2026, licensing inspection.
A plan of correction for ensuring the proper initial dosage level for a patient was submitted and approved by the Department for the May 1, 2024 and April 25, 2025, annual licensing inspections. Failing to ensure the proper initial dosage level for a patient was again found to be a deficiency in the April 7, 2026 through April 10, 2026, licensing inspection.
A plan of correction for ensuring the completion of both communicable disease trainings within the required timeframe was submitted and approved by the Department for the May 1, 2024 and April 25, 2025, annual licensing inspections. Failing to complete both communicable disease trainings within the required timeframe was again found to be a deficiency in the April 7, 2026 through April 10, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PLAN OF CORRECTION (POC)
Facility Name: Beacon Point Recovery Center
Regulation Cited: Compliance with Approved Plans of Correction
Date of Inspection: April 7 to April 10, 2026
1. Statement of the Deficiency
Based on an administrative review of facility records, the facility failed to maintain ongoing compliance with previously submitted and approved Plans of Correction. The facility acknowledges that once a Plan of Correction is approved, the corrective actions, monitoring process, responsible parties, and completion timelines become ongoing compliance obligations.
The facility further acknowledges that failure to sustain compliance with approved Plans of Correction reflects a breakdown in administrative oversight, tracking, accountability, and quality assurance follow-through.
2. Corrective Action(s) Taken and Planned
Beacon Point Recovery Center has deleted the prior corrective plan specific to individual repeated citations and has replaced it with a facility-wide Plan of Correction Oversight Process designed to ensure that all approved Plans of Correction are implemented, monitored, documented, and sustained going forward.
Plan of Correction Tracking Log:
The facility has developed and implemented a centralized Plan of Correction Tracking Log. This log will include each cited regulation, the approved corrective action, the responsible job title, the required monitoring activity, the target completion date, and the date compliance was verified.
Assignment by Job Title:
Each corrective action will be assigned to a responsible department head or leadership position by job title only. Responsible parties may include, but are not limited to, the Executive Director, Director of Compliance, Director of Nursing, Medical Director, Clinical Director, Human Resources Director, Training Coordinator, and Department Supervisors.
Leadership Review of All Active Plans of Correction:
The Executive Director and Director of Compliance will review all active and previously approved Plans of Correction to ensure that each corrective action has been fully implemented and remains in effect. Any missing documentation, incomplete monitoring, or unclear ownership will be corrected and added to the centralized tracking process.
Policy and Procedure Integration:
Corrective actions from approved Plans of Correction will be incorporated into facility policies, procedures, audit tools, onboarding checklists, training records, and department workflows as applicable. This will ensure that compliance does not depend on memory, informal communication, or one-time correction.
Department Head Accountability:
Department heads will be responsible for maintaining compliance with approved Plans of Correction that apply to their areas. Compliance with assigned corrective actions will be reviewed as part of routine supervision, department meetings, and performance accountability.
Staff Education:
Leadership staff and department supervisors will receive education on the requirement to follow approved Plans of Correction as ongoing regulatory obligations. This education will include how corrective actions are tracked, how documentation must be maintained, and how concerns are escalated when compliance cannot be immediately verified.
3. Plan for Monitoring and Quality Assurance
To ensure continued compliance with all approved Plans of Correction, the following monitoring process has been implemented:
Monthly Plan of Correction Audit:
The Director of Compliance will conduct a monthly audit of the centralized Plan of Correction Tracking Log. The audit will verify that each active corrective action has been implemented, required documentation is present, and ongoing monitoring is occurring as written.
Quarterly Leadership Review:
The Executive Director, Director of Compliance, and applicable department heads will review all active Plans of Correction on a quarterly basis. This review will evaluate whether corrective actions remain effective, whether documentation supports ongoing compliance, and whether additional action is needed.
Corrective Action Escalation Process:
If an audit identifies that a corrective action has not been completed, is not properly documented, or is not being sustained, the Director of Compliance will immediately notify the Executive Director and the applicable department head. A written follow-up action will be assigned, tracked, and verified through the Plan of Correction Tracking Log.
Documentation Retention:
Documentation supporting implementation and monitoring of approved Plans of Correction will be maintained in a designated compliance file. This may include audit tools, training records, meeting minutes, policy revisions, corrective action forms, and verification checklists.
Annual Compliance Validation:
At least annually, the Executive Director and Director of Compliance will complete a comprehensive review of approved Plans of Correction from the prior licensing cycle to confirm that corrective actions remain active, measurable, and sustained.
4. Title of Person Responsible for Implementation
Executive Director
Director of Compliance
Applicable Department Heads by Area of Responsibility
5. Target Completion Date
Plan of Correction Tracking Log Implemented: June 21, 2026
Full Compliance Reached: June 21, 2026 |