INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 2, 2011 licensure renewal inspection. The follow-up inspection was conducted on February 21, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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
|
709.24(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.
|
Observations
Based on 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:
An interview with the facility director on February 21, 2012 provided verification that provisions have not been made through written agreement with either a licensed hospital or physician for 24 hour medical coverage.
|
Plan of Correction
Facility director has contacted Community Medical Center and is waiting for a response on what is needed to obtain a written agreement to provide 24 hour emergency medical coverage. This will be followed up on within the next month if a response is not recieved. Hopefully this agreement will be in place within the next 1-3 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 on an interview, the facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with drug and alcohol abuse services.
The findings include:
The project's fiscal year is January through December annually. The project failed to document a fiscal audit of financial activities associated with the drug and alcohol abuse services for calendar year 2010.
On February 21, 2012 the facility director confirmed an annual audit has not been completed for the 2010 calendar year.
|
Plan of Correction
Facility director has submitted a Request for Exception to the Division of Drug and Alcohol Program Licensure. This request was sent on 2/22/12. As of today's date a response to this request has not been received. Once this is received, we will have a better understanding as to what direction to take in regards to having an audit performed.
Hopefulluy, this will be taken care of 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).
|
Observations
Based on an interview, the facility failed to provide a physician signature on treatment plans and treatment plan updates.
Findings:
The facility director stated during an interview that the representative from the managed care entity subcontracting with the Office of Medical Assistance indicated that the physician signature was not required on treatment plans and treatment plan updates. The facility director then confirmed that there would be no documentation in the records of physician signatures on the client records.
An interview with the facility director on February 22, 2012 verified that the facility failed to comply with 55 Pa. Code Part III in regard to medical assistance reimbursement.
|
Plan of Correction
Facility director will obtain a physian signiture on treatment plans and treatment plan updates for all Medical Assistance clients.
THis will be obtained within the next 1-2 months. |