INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 4, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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) 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.
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Observations
Based on the review of four client records, the project failed to document an informed and voluntary consent to disclose information in one record. Client # 1 was admitted on June 6, 2018 and was still active at the time of inspection. The project failed to document an informed and voluntary consent to disclose information for the client's funding source.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection on October 9, 2018.
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Plan of Correction
The C.E.O. Will obtain will obtain all informed and voluntary consents from each client to release information during the initial session, and/or whenever the client would like to have any information released. This will be signed and dated by both the client and the C.E.O. This will be reviewed thru the use of a log sheet that will determine when the next release will need to be updated if necessary. The C.E.O. review all client files monthly to see what updates, if any, are needed. This will be implemented by 11/1/2019. |
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 a review of the facilities data collection system, it was determined that the facility failed to maintain a recordkeeping system that allowed for the identification of clients' admissions and discharges within specific time periods. The facility's recordkeeping system does not separate the drug and alcohol rehabilitation clients from the clients receiving mental health services.
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Plan of Correction
The C.E.O. will be responsible for implementing a record keeping system that will identify each client's admission and discharge dates. A log will be established and will be reviewed and monitored by the C.E.O.
This will be implemented within the next month - 11/1/2019.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of four client records, the facility failed to document a preliminary treatment and rehabilitation plan for one client.Client #4 was admitted on August 16, 2019 and was still active at the time of inspection. A preliminary treatment plan was not completed at intake.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The C.E.O. will complete a preliminary treatment plan with each client during their initial intake session. This will be dated and signed by both the client and C.E.O. All client records will be reviewed on a monthly basis by the C.E.O. to make sure all necessary information that is needed is in the file. A log sheet will be completed to document what information is needed in each file. This will be implemented by 11/1/2019. |
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 a review of four client records, the facility failed to document treatment and rehabilitation plan updates at least every 60 days in two client records reviewed.Client #1 was admitted on June 6, 2018 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on April 9, 2019 and the next update was due no later than June 9, 2019; however, there was no update documented in the record until July 30, 2019.Client #3 was admitted on July 5, 2018 and was still active at the time of the inspection. A treatment and rehabilitation plan update was completed on November 26, 2018 and the next update was due no later than January 26,2019; however, there was no update documented in the record until February 4, 2019. Additionally, a treatment and rehabilitation plan update was completed on April 15, 2019 and the next update was due no later than June 15, 2019; however, there was no update documented in the record until July 8, 2019. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from last year's licensure renewal inspection conducted on October 9, 2019.
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Plan of Correction
The C.E.O. will complete and document a treatment and rehabilitation plan with each client at least every 60 days or before. This will be signed and dated by both the client and the C.E.O. This will be reviewed by the C.E.O. on a monthly basis to ensure all information is completed in a timely manner. A log sheet will be kept in each client file to determine when things are due. This will be implemented by !!/1/2019. |