INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 25, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lighthouse Counseling Associates 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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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on one of four client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information keeping the information disclosed within the limits of 255.5 (a) (6) to an employer.Client # 3 was admitted on February 20, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to an employer dated February 20, 2021 allowed for the release of Attendance, progress, and recommendations.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Informed voluntary consents will be obtained from all clients to disclose any information contained in the client record. All consents will be in writing and will include specific information to be disclosed.
This will be implemented and reviewed by therapist.
This will be implemented within 1 month. |
709.29 (a) LICENSURE Retention of client records
§ 709.29. Retention of client records.
(a) Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client.
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Observations
Based on an onsite licensing inspection and the request for client records, the facility was unable to provide the requested client records. Two discharged client records from the last inspection were unable to be located.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Retention of client records: Client records will be readily accessible for review for a minimum of 4 years following discharge of a client.
This will be implemented by the CEO/therapist within 1 month |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on two of two applicable client records reviewed, the facility failed to inform clients of their rights. After a discussion with the facility director, client rights were to be verbally explained to the clients by the director however, this was not occurring.Client # 1 was admitted on January 11, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification however, after confirmation with the facility director, client rights were not being verbally explained to the client.Client # 3 was admitted on February 2, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification however, after confirmation with the facility director, client rights were not being verbally explained to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A document outlining and explaining the policies and procedures on client rights will be developed by the CEO. This document will then be given to each client, on admission, and explained to the client. The client will then sign off acknowledging that this was received and explained during their initial session.
This will be implemented within 1 month. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on two of two applicable client records reviewed, the facility failed to make the client aware of the criteria for admission, treatment, completion and discharge. Client # 1 was admitted on January 11, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification of admission and intake however, after confirmation with the facility director, a complete description of regulatory information had not been conveyed to the client.Client # 3 was admitted on February 20, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification of intake and admission however, after confirmation with the facility director, a complete description of regulatory information had not been conveyed to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake procedures will include criteria for admission, treatment, completion and discharge. Each client will be made aware of this on their initial session. This will be documented and included in the client record.
The CEO/therapist will be responsible for implementing this. This will be implemented within 1 month. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on two of two applicable client records reviewed, the facility failed to familiarize the client with the project policies. Client # 1 was admitted on January 11, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification of admission and intake however, after confirmation with the facility director, a complete description of regulatory information had not been conveyed to the client.Client # 3 was admitted on February 20, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification of intake and admission however, after confirmation with the facility director, a complete description of regulatory information had not been conveyed to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake procedures will include documentation that every client was oriented to the facilities policies. This will be done on the clients initial session. This documentation will be then included within the client record.
The CEO/therapist will be responsible for reviewing and implementing this with the client.
This will be implemented in 1 month.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on two of two applicable client records reviewed, the facility failed to familiarize the client with the hours of operation. Client # 1 was admitted on January 11, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification of admission and intake however, after confirmation with the facility director, a complete description of regulatory information had not been conveyed to the client.Client # 3 was admitted on February 20, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification of intake and admission however, after confirmation with the facility director, a complete description of regulatory information had not been conveyed to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake procedures will include documentation that each client was oriented to the facilities procedures (hours of operation). This will be implemented and documented with the client on their initial session. This documentation will then be included within the client record.
The CEO/therapist will be responsible for implementing and documenting this with each client.
This will be implemented within 1 month. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on two of two applicable client records reviewed, the facility failed to familiarize the client with the fee schedule. Client # 1 was admitted on January 11, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification of admission and intake however, after confirmation with the facility director, a complete description of regulatory information had not been conveyed to the client.Client # 3 was admitted on February 20, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification of intake and admission however, after confirmation with the facility director, a complete description of regulatory information had not been conveyed to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake procedures will include documentation that each client was oriented to the facilities procedures (fee schedules). This will be implemented and documented with each client during their initial session. This will then be included within the client record.
The CEO/therapist will be responsible for implementing and documentation of this.
This will be implemented within1 month. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on two of two applicable client records reviewed, the facility failed to familiarize the client with the services provided. Client # 1 was admitted on January 11, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification of admission and intake however, after confirmation with the facility director, a complete description of regulatory information had not been conveyed to the client.Client # 3 was admitted on February 20, 2021 and was still active at the time of the inspection. The client signed a checklist of the notification of intake and admission however, after confirmation with the facility director, a complete description of regulatory information had not been conveyed to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake procedures will include documentation that each client will be oriented to the facilities procedures ( treatment services being offered). This will be implemented and documented on the clients initial session. This will then be included within the client record.
The CEO/therapist will be responsible for implementation of this.
Implementation will be done within 1 month. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on one of three applicable client records reviewed, the facility failed to provide documentation of a treatment and rehabilitation plan being reviewed and updated at least every sixty days.Client # 4 was admitted on June 6, 2018 and was still active at the time of the inspection. A treatment plan update occurred on November 4, 2019. The next update was due to occur on January 19, 2020 but was not developed until February 19, 2020. The next update was due on April 19, 2020 but was not developed until June 9, 2020. The next update was due August 2, 2020 but was not developed until September 2, 2020. The next was due November 2, 2020 but was not developed until December 30, 2020.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from September 5, 2019 and October 9, 2018 licensing inspection
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Plan of Correction
Treatment plan updates will be completed with each client every 60 days from the initial treatment plan. This will be implemented by the CEO/therapist, and included in the client record.
This will be implemented within 1 month. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on one of one applicable client records reviewed, the facility failed to provide an aftercare plan in accordance with the facility policy and procedure manual. Client # 2 was admitted on July 5, 2018 and was successfully discharged on October 15, 2019. Documentation of an aftercare plan was not provided in the client record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Aftercare policies will be completed on every client that successfully discharges from the facility. This will be included within the client record.
The CEO/therapist will be responsible for implementing this as well as making sure this is completed.
This will be implemented within 1 month. |