INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 6, 2024 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure each employee had a written individual training plan, with input from both the employee and the supervisor, in one of one personnel record reviewed.
Employee #1 was hired as the project director/facility director on September 1, 1992. There was no current individual training plan documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Individual Training Plans will be completed yearly and in a timely manner. This will be completed and placed in the personnel file
This will be completed by and monitored by the CEO of the facility.
This will be completed within the next month. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed as there was a space heater located in the project director/facility director's office.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Heating and Cooling:
No heaters that are not permanently mounted or installed will be utilized within the facility.
The CEO will be responsible for following thru and monitoring this.
This will be completed immediately.
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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 one of two client records reviewed.
Client # 1 was admitted on March 29, 2023 and was 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.
This is a repeat citation from the September 11, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Confidentiality:
Informed and Voluntary consents to release information will be completed on each client receiving treatment within the facility.
This will be signed by the client and therapist and updated if needed every 6 months according to policies and procedures.
This will be followed up and monitored by the CEO. This will be done immediatly.
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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 is a repeat citation from the September 11, 2023 annual licensing renewal inspection.
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 is a repeat citation from the September 11, 2023 annual licensing renewal inspection.
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 theft, burglary, break-ins, or similar incidents. This will be completed by the CEO of the facility and put into place.
This will occur within the 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 is a repeat citation from the September 11, 2023 annual licensing renewal inspection.
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 accomplished 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 is a repeat citation from the September 11, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The policy on unusual incidents 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 accomplished within the next 3 months. |