INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's November 1, 2021 through October 31, 2022 training year in one of one personnel record reviewed.
Employee # 1 was hired as the project/facility director/counselor on September 1, 1992. The personnel record documented 6.5 hours of training received during the training year reviewed.
This is a repeat citation from the September 13, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Lighthouse Counseling Associates will ensure that 25 hours of training will occur annually. This will be done by researching trainings available, scheduling the training, attending the training, and documenting this within the personnel file. The certificate of attendees will be included within the personal file. Trainings will be continue monitored to make sure they are scheduled in advance in order to ensure the 25 hours are completed in ample time.
The CEO will be responsible for monitoring this.
This will take place within the next month. |
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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of two applicable client records reviewed.
Client # 1 was admitted on March 29, 2023 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 2 was admitted on January 11, 2021 and was discharged on October 15, 2022. The release of information form to the funding source was signed by the client on January 11, 2021 and it expired on July 11, 2021. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after July 11, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each client will complete an informed and voluntary consent to release information on their first initial session at the facility. This release will be explained to the client. Both the client and therapist will sign the release. The release will then be placed within the client record. The release will be dated. This will be monitored on a consistent basis, monthly to ensure all releases are up to date. The CEO of the facility will be responsible for this as well as carrying this out.
This will take place within the next month. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their regulatory client rights.
Every client record reviewed had a client rights acknowledgment form; however, the form did not include any of the six regulatory client rights the client must have written acknowledge for.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Each client admitted into the facility will be informed of their regulatory rights on their initial session. This will be reviewed and explained in detail at this time and then included within the client record.
The client rights acknowledgement form will be updated to include the six regulatory rights the client must have written acknowledgement for. This will be completed and carried out by the CEO of the facility. This will be monitored on a consistent basis, to ensure this is being carried out, by chart audits. The CEO will also be responsible for this.
This will take place within the next 3 months. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop and implement unusual incident reporting policies and procedures on how the facility would respond to the selling or use of illicit drugs on the premises.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The unusual incident policy will be updated to include policies and procedures on how the facility will respond to the selling or use of illegal drugs on the premises. This will be completed by the CEO of the facility and put into place.
This will occur within the next 3 months. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop and implement unusual incident reporting policies and procedures on how the facility would respond to theft, burglary, break-in, or similar incident at the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The policy on unusual incident reporting will be updated to include how the facility will respond to theft, burglary, break-in, or similar incidents. The CEO of the facility will be responsible for this. This will be properly documented and put into effect.
This will be initialed within the next 3 months. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to include, in their unusual incident policy, the written procedures to follow regarding the prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The unusual incident policy will be updated to include the prompt review and identification of the causes directly related or indirectly responsible for the unusual incident. The CEO of the facility will be responsible for completing this update and will document .
This will be initialed within her next 3 months. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to include, in their unusual incident policy, the written procedures to follow regarding the implementation of a timely and appropriate corrective action plan, when indicated.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The unusual incident policy will be updated. The written procedures will include the implementation of a timely and appropriate corrective action plan when an incident occurs. The CEO of the facility will be responsible for the update and will put in effect.
This will be initialed within the next 3 months. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to include, in their unusual incident policy, the written procedures to follow regarding the ongoing monitoring of the corrective action plan.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The policy on unusual incident will be updated and will include the procedures to follow the ongoing monitoring of the corrective action plan. The CEO of the facility will be responsible for this update and putting it into effect.
This will be initialed within the next 3 months. |