INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 31, 2017, 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 to be not 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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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
A physical plant inspection was conducted on August 31, 2017. The facility failed ensure that bathrooms are ventilated with an exhaust fan or window.The facility bathroom did not have a window and the exhaust fan was not working.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The C.E.O. of the facility will contact the landlord and inform him that the bathroom fan is not working, and is in need of repair or replacement. This will be done immediately and will plan on this to be in working order within the next month,11/21/2017. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) 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, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of Presubmission materials and a conversation with the facility staff conducted on August 31, 2017, the facility failed to provide documentation that the annual report was made available to the public.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The C.E.O. will contact the local newspaper and have an announcement posted that the Annual Report is ready for review. Documentation once in the newspaper will be kept and provided within a file for licensing to review during site inspection. This will be accomplished within the next 1-3 months. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Seven client records were reviewed on August 31, 2017. The facility failed to document a psychosocial evaluation in client records, #5 & 7.Client #5 was admitted on 2/28/17 and was an active client at the time of the licensing inspection. A psychosocial evaluation was started at intake but was not completed. The section where the clinical evaluation would be documented was blank.Client #7 was admitted on 1/28/17 and was discharged on 2/28/17. There was no psychosocial evaluation documented at the time of the licensing inspection.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Psycho social evaluations will be completed by all primary therapists. This will be completed on all patients within 30 days of their admission to the facility.
In regards to the charts that were reviewed during the inspection, the charts that did not have psychosocial evaluations completed, will be completed within the next month. This will in turn be documented and kept within the patient record. |