INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 11, 2007 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 and a plan of correction is due on November 6, 2007.
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on October 11, 2007 it was determined that the nonresidential facility failed to ventilate the bathroom by either an exhaust fan or window. The exhaust fan in the bathroom was not functional at the time of the inspection and there is no window in the bathroom.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 policy and procedure and client records it was determined that the outpatient project failed to comply with the Department of Public Welfare's medical assistance manual (55 Pa. Code Part III). Three of three client records reviewed on October 11, 2007, where the Office of Medical Assistance is the funding source, failed to include physician oversight and review. Treatment plans and sixty-day treatment plan updates did not include sign off and review by the facility medical director.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |