INITIAL COMMENTS
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This report is a result of an on-site licensure renewal survey conducted on August 2, 2011 by staff from the Division of Drug and Alcohol 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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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement and an interview with the project director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
Letters of agreement were reviewed on August 2, 2011. The only letter of agreement regarding 24- hour emergency coverage was signed with a local hospital on June 3, 2004 for emergency psychiatric coverage. There was no other documentation of a 24- hour emergency medical coverage agreement.
The project director was interviewed on August 2, 2011. It was confirmed at that time that there was no documentation of an agreement for 24- hour emergency medical coverage.
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Plan of Correction
Project Director will obtain an agreement with a local hospital regarding 24 hour emergency medical coverage, as well as 24 hour emergency psychiatric coverage.
This will be completed within the next 3mths. |
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.
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Observations
Based on a review of administrative policies, procedures, protocol manual and an interview the facility failed to obtain an independent audit of financial activities associated with the drug/alcohol abuse services.
Findings:
A review of administrative policies and procedures, and an interview with the project director/owner was conducted on August 2, 2011. Per regulation, 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. The project's fiscal year is from January 1, 2010 through December 31, 2010. The audit for January 1, 2010 through December 31, 2010 was not available for review as of August 2, 2011. The project failed to obtain an annual audit for the 2010 fiscal year.
On August 2, 2011 the project director/owner confirmed the 2010 audit had not been completed.
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Plan of Correction
Project Director will submit a request to be exempted from an audit based on the fact that Lighthouse Counseling Associates is a very small private practice and obtaining an audit does not appear to be cost effective.
If this request is not accepted Lighthouse Counseling Associates will have their accountant perform an annual audit.
This request will be completed within the next month. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of the client records and an interview the facility failed to provide a physician signature on treatment plans and treatment plan updates in three of three client records.
Findings:
Four client records were reviewed on August 2, 2011. Three of the four records included documentation confirming funding by the office of medical assistance and were required to include documentation of physician signatures on the treatment plans and the treatment plan updates. Three of three client records failed to include a physicians review and signature on treatment plans and treatment plan up-dates.
Client record # 1 - The client was admitted to treatment on May 12, 2011. The treatment plans were completed on May 12, 2011 and June 12, 2011. Physician review and signatures were not documented on two of the two treatment plans reviewed on August 2, 2011.
Client record # 2 - The client was admitted to treatment on March 24, 2011. The treatment plans were completed on March 24, 2011, April 24 2011 and June 24, 2011. Physician review and signatures were not documented on three of three treatment plans reviewed on August 2, 2011.
Client record # 3 - The client was admitted to treatment on March 29, 2011. The treatment plans were completed on March 29, 2011, April 29, 2011 and June 29, 2011. Physician review and signatures were not documented on three of three treatment plans reviewed on August 2, 2011.
In the discussion with the project/facility director on August 2, 2100 it was confirmed the physician review and signatures were not documented on the treatment plans reviewed. The project/facility director indicated during the discussion physician review and signatures are not required for mental health records.
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Plan of Correction
Project Director will be responsible for having a physicial signiture on all treatment plans and treatment plan updates associated with Medical Assistance patients.
This will be accomplished within the next 3 months. |