INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 9, 2018 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:
|
Plan of Correction
|
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.
|
Observations
Five client records were reviewed on October 9, 2018. The facility failed to obtain an informed and voluntary consent where consent was applicable for client records # 1 and 3.
Client # 1 was admitted into treatment on April 4, 2018 and was still active in treatment. A consent to release information to the client's treatment funding source, an immediate relative, was not documented in the client's record.
Client # 3 was admitted into treatment on June 6, 2018 and was still active in treatment. A consent to release information to the client' treatment funding source, an insurance company, was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The C.E.O./Primary Therapist will obtain informed and voluntary consents from all clients where a consent in warranted.
This will be done immediately. |
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.
|
Observations
Five client records were reviewed on October 9, 2018. The facility failed to document a treatment plan update at least every 60 days for client records # 1 and 3.
Client # 1 was admitted into treatment on April 4, 2018 and was still active in treatment. A comprehensive treatment plan was completed for the client on May 16, 2018. The first treatment plan update documented in the client's record was completed on July 25, 2018.
Client # 3 was admitted into treatment on June 6, 2018 and was still active in treatment. Both a comprehensive treatment plan and a treatment plan update were completed for the client on July 16, 2018. A subsequent treatment plan update was due to be completed for the client by September 14, 2018, and one was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The C.E.O./Primary Therapist will complete a treatment plan update on every client every 60 days. The updates will be included in the client record.
This will be done Immediately. |