INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on August 15, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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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709.22(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:
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Observations
Based on a review of the annual report, the facility failed to make the annual report available to the public.
The findings include:
The annual report for the June 30,2010 to July 1, 2011 year was reviewed on August 15, 2012. The annual report was not fully made available to the public. The facility did provide advertisements to organizations with whom they have professional contact but were unable to provide evidence of notification provided to the general public.
This was discussed with and confirmed by the Project/Facility Director on August 15, 2012.
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Plan of Correction
THe annual report will be made available to the public by putting a notice in the local newspaper stating that the annual report is ready for review. THis will be carried out by the CEO/Project director of the facility within the next 6 months.
Correction:
The annual report will be made available to the public by putting a notice in the local newspaper stating that hte annual report is ready for review. THis will be carried out by the CEO/Project DIrector Jacqueline Costello. She will contact the Scranton TImes, and the Triboro Banner to have this notice submitted within the next 3 months. Once this is availbale in the newspaper, a copy will be kept on record to ensure this notification took place.
Correction:
The annual report will be made available to the public by putting an advertisement in the local newspaper, Scranton Times, and Triboro Banner, stating that the annual report is ready for review. In order for this to take place Jacqueline Costello, C.E.O./ Project Director, of the facility will contact the newspapers noted above. Once this has been posted in the newspaper a copy of the advertisement will be kept on file to assure that the notification took place. THis will take place within 3 months of this date 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.
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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:
The letters of agreement were reviewed on August 15, 2012. The Facility /Project Director stated a contract to have coverage was sent to a local hospital, however, an agreement was not in place at the time of the inspection.
The project director was interviewed on August 15, 2012. It was confirmed at that time that there was no documentation of a 24- hour emergency medical coverage.
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Plan of Correction
A letter of agreement with a local hospital documented 24 hour emergency medical coverage will be implemented.
This will be carried out by the CEO/Project Director of the facility within the next 3 months.
Correction:
A letter of agreement with a local hospital documenting 24 hour emergency medical coverage will be implemented. THis will be carried out by the CEO/Project Director, Jacqueline Costello. She will contact Community Medical Center/Geisinger to see what needs to be done in order to have this implemented. This will occur within the next 3 months.
Correction:
A letter of agreement with a local hospital documenting 24 hour emergency medical coverage will be implemented. This will be carried out by the CEO/Project DIrector of the facility, Jacqueline Costello. She will contact Community Medical Center/Geisinger to see what needs to be cone in order to have this implemented. THe will occur within the next 2 months, as noted in the corrective action date above. |