INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 29, 2013, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
|
Plan of Correction
|
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
|
Observations
Based upon the review of administrative documentation, the facility failed to include a financial statement of income and expenses in the 2012 annual report and failed to provide verification that the 2012 annual report was made available to the public.
The findings include:
Administrative documentation, including the 2012 annual report, was reviewed on August 29, 2013. The facility failed to include a financial statement of income and expenses in the 2012 annual report and failed to provide verification that the 2012 annual report was made available to the public.
The findings were confirmed by the project's CEO during the exit interview.
|
Plan of Correction
The CEO will make public that the annual report is ready for review. This will be put in the local newspaper. A copy, when posted, will be included in records and will be provided during licensing visit.
This will be completed within the next 3 months. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based upon the review of administrative documentation, the facility failed to provide the required documentation in regard to its financial activities for 2012.
The findings include:
Administrative documentation was reviewed on August 29, 2013. The project had an exception to obtaining an annual audit of financial activities but was required to provide copies of its federal, state and local tax returns in lieu of the audit. The facility failed to provide copies of its 2012 federal, state and local tax returns on the date of inspection.
The findings were confirmed by the project's CEO.
|
Plan of Correction
The 2012 federal, state and local tax returns were not provided on date of inspection due to the fact that an extension was filed and the tax returns were not completed at the time of inspection.
The CEO will provide all tax returns as deemed necessary during all licensing visit. This will go into effect immediately.
|
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based upon the review of client records and an interview with the project's CEO, the facility failed to ensure that it did not disclose client information without an informed and voluntary consent form in two of five client records.
The findings include:
Five client records requiring informed and voluntary consent forms were reviewed on August 29, 2013. The facility failed to ensure that it did not disclose client information without an informed and voluntary consent form in client records # 3 and 5.
Client # 3 was admitted on December 10, 2011 and was still an active client on August 29, 2013. The record included a consent to release information form for a release of information to the client's funding source that was signed by the client on December 10, 2011 with an expiration date of June 10, 2012. The record did not include any other consent to release information forms for a release of information to the client's funding source. The record also included a record of services that contained documentation of individual sessions conducted between June 11, 2012 and the date of inspection. The facility failed to ensure that it did not disclose client information without an informed and voluntary consent to release information form as the project's CEO confirmed that the funding source for client # 3 was billed for client services provided after the consent form had expired.
Client # 5 was admitted on May 11, 2012 and was discharged on January 15, 2013. The record included a consent to release information form for a release of information to the client's funding source that was signed by the client on May 11, 2012 with an expiration date of November 11, 2012. The record did not include any other consent to release information forms for a release of information to the client's funding source. The record also included a record of services that contained documentation of an individual session that was conducted on December 13, 2012. The facility failed to ensure that it did not disclose client information without an informed and voluntary consent to release information form as the project's CEO confirmed that the funding source for client # 5 was billed for client services provided after the consent form had expired.
|
Plan of Correction
All voluntary and informed consent forms will be signed and dated by client. Any expired consents will be updated on a consistent and timely basis.
The CEO will be responsible for carrying this out.
This will go into effect immediately. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. 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:
(3) Proposed type of support service.
|
Observations
Based upon the review of client records, the facility failed to document an individual treatment plan that included proposed type of support services in two of five client records.
The findings include:
Two client records requiring documentation of proposed type of support services on the individual treatment plan were reviewed on August 29, 2013. The facility failed to document the proposed type of support services on treatment plans in client records # 1 and 2.
Client # 1 was admitted on July 3, 2013, and was still an active client on the date of inspection. The record contained a treatment plan that was signed by the client on August 3, 2013, that did not include proposed type of support services.
Client # 2 was admitted on July 6, 2013, and was still an active client on the date of inspection. The record contained a treatment plan that was signed by the client on August 6, 2013, that did not include proposed type of support services.
The findings were confirmed with the project's CEO during the exit interview.
|
Plan of Correction
All treatment plans will contain documentation of specific proposed types of support services to be utilized by the client.
The CEO will be responsible for carrying this out.
This will go into effect immediately. |