INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 6-7, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Beyond Addiction Recovery and Treatment Center LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include, but not limited to, written documentation of type and frequency of treatment and rehabilitation services.
Client #2 was admitted on October 4, 2025, and was still active at the time of the inspection. A treatment plan was developed on October 8, 2025, with no frequency of treatment identified.
Client #3 was admitted on September 30, 2025, and was still active at the time of the inspection. A treatment plan was developed on October 6, 2025, with no frequency of treatment identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Chief Clinical Officer met with clinical team after onsite inspection at which time she educated the clinical staff on creating more individualized and concrete timelines and frequencies for clients in their treatment plan. CEO also contacted the EHR system to create more detailed charting. EHR added additional information into how we can input data into charts.
All client's charts were updated to reflect frequency of treatment types in treatment plans and were discussed with clients and signed off by staff. Updated treatment plans were created for all deficiencies found.
CCO and UR Specialist will run weekly chart audits to ensure clinical staff is created more detailed treatment plans with frequencies of treatment identified. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframes.
Client #1 was admitted on September 24, 2025, and was still active at the time of the inspection. A treatment plan was completed on September 30, 2025, and the next update was due no later than October 30, 2025; however, there were no updated treatment plans documented in the client record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Chief Clinical Officer met with clinical team after onsite inspection at which time she educated the clinical staff on creating more individualized and concrete timelines and frequencies for clients in their treatment plan. CEO also contacted the EHR system to create more detailed charting. EHR added additional information into how we can input data into charts.
Client #1's treatment plan was updated on 11/11/2025 at 10:28 AM and was reviewed with the client and signed off by counselor on that date and time.
CCO and UR Specialist will run weekly chart audits to ensure clinical staff is created more detailed treatment plans with frequencies of treatment identified. |