INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 23, 2015 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:
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
The facility failed to meet the pre-submission guidelines for the annual licensing inspection. The time allotted for the onsite portion of the inspection did not allow for a thorough review of that material on site.
This matter was reviewed with facility staff during the licensing process.
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Plan of Correction
Pre-submission guidelines for the annual licensing inspection will be submitted on time, prior to the next licensing visit in order for it to be reviewed.
The C.E.O. will be responsible for this. This will be accomplished prior to the next upcoming licensing visit - 2016. |
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 administrative documentation, the project failed to make the annual report available to the public.
The findings include:
Based on a review of administrative documentation during a renewal inspection on July 23, 2015, the project failed to provide verification that an annual report has been made available to the public.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the licensing renewal inspection conducted on July 21, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The annual report will be made available to the public via being placed in the local newspaper. Verification of this will be provided during next licensing visit - 2016.
The C.E.O. will be responsible for this. This will be accomplished within the next 3 months. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of treatment services on the individual treatment and rehabilitation plan in two of six client records reviewed.
The findings include:
Six client records requiring documentation of the type and frequency of treatment services on the individual treatment and rehabilitation plans were reviewed on 7/23/15. The individual treatment and rehabilitation plans contained in client records # 2 and 5 did not include the frequency of treatment services.
Client # 2 was admitted into treatment on 10/7/14 and was still active at the time of the inspection. The client's individual treatment and rehabilitation plan dated 11/7/14 did not specify the frequency of individual counseling therapy.
Client # 5 was admitted into treatment on 1/14/14 and was discharged on 10/1/14. The client's individual treatment and rehabilitation plan dated 2/14/14 did not specify the frequency of individual counseling therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Documentation of the frequency of treatment services on the individual treatment plan will occur within all client records.
The C.E.O. as well as any and all future contracted staff will be responsible for carrying this out.
This will occur immediately. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that counseling services are provided according to the individual treatment and rehabilitation plan in six of six client records reviewed.
The findings include:
Six client records were reviewed on July 23, 2015. The facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plan in records # 1, 2, 3, 4, 5, and 6.
Client # 1 was admitted into treatment ton 7/23/15 and was still active at the time of the inspection. The client's master treatment plan dated 5/2/14 indicated that the client was to receive individual counseling once a week. The client's last three treatment plan updates, dated 7/3/15, 5/2/15, and 3/3/15, indicated that the client was to receive individual counseling once bi-weekly. The client received individual counseling sessions on the following dates: 7/8/15, 6/23/15, 6/9/15, 5/26/15, 4/13/15, 3/31/15, 3/17/15, 2/16/15, 2/2/15, 1/12/15, 12/29/14, 12/9/14, 11/26/14, 11/13/14, 10/23/14, 10/9/14, 9/15/14, 9/4/14, 8/26/14, and 8/8/14. A progress note from the client's last counseling session on 7/8/15 indicated that the next scheduled counseling session was 8/4/15.
Client # 2 was admitted into treatment on 10/7/14 and was still active at the time of the inspection. The client's master treatment plan dated 11/7/14 indicated that the client was to receive individual counseling, but did not specify the frequency of treatment. All of the client's treatment plan updates indicated that the client was to receive individual counseling once bi-weekly. The client received individual counseling sessions on the following dates: 7/1/15, 6/5/15, 5/15/15, 4/17/15, 3/4/15, 2/18/15, 1/23/15, 1/9/15, 12/10/14, 11/19/14, 11/5/14, 10/24/14, and 10/7/14. A progress note from the client's last counseling session on 7/1/15 indicated that the next scheduled counseling session was 7/24/15.
Client # 3 was admitted into treatment on 9/29/14 and was still active at the time of the inspection. The client's master treatment plan dated 10/29/14 indicated that the client was to receive individual counseling once a week. The client's last two treatment plan updates, dated 4/29/15 and 6/29/15, indicated that the client was to receive individual counseling once bi-weekly. The client received individual counseling sessions on the following dates: 7/20/15, 6/26/15, 5/22/15, 5/13/15, 4/27/15, 4/13/15, 3/25/15, 3/10/15, 2/25/15, 2/13/15, 1/26/15, 1/15/15, 1/8/15, 1/2/15, 12/22/14, 10/22/14, 10/14/14, 10/7/14, and 9/29/14.
Client # 4 was admitted into treatment on 5/23/15 and was still active at the time of the inspection. The client's master treatment plan dated 6/23/15 indicated that the client was to receive individual counseling once a week. The client received individual counseling sessions on the following dates: 7/10/15, 6/20/15, 6/6/15, 5/28/15, and 5/23/15.
Client # 5 was admitted into treatment on 1/14/14 and was discharged on 10/1/14. The client's master treatment plan dated 2/14/14 indicated that the client was to receive individual counseling, but did not specify the frequency of treatment. The client's treatment plan updates dated 4/14/14 and 6/14/14 indicated that the client would receive individual counseling once a week. The last treatment plan update for the client, dated 8/14/14, indicated that the client would receive individual counseling once a week or bi-weekly. he client received individual counseling sessions on the following dates: 9/12/14, 8/29/14, 8/8/14, 7/25/14, 6/20/14, 6/13/14, 5/30/14, 5/23/14, 5/16/14, 5/2/14, 4/4/14, 3/28/14, 3/21/14, 3/7/14, 2/21/14, 2/14/14, 2/6/14, 1/31/14, 1/24/14, and 1/14/14.
Client # 6 was admitted into treatment on 2/3/14 and was discharged on 8/15/14. The client's master treatment plan dated 3/3/14 indicated that the client was to receive individual counseling once a week. The client's treatment plan updates dated 5/3/14 and 7/3/14 also indicated that the client would receive individual counseling once a week. The client received individual counseling sessions on the following dates: 7/22/14, 7/1/14, 6/17/14, 5/20/14, 5/13/14, 5/6/14, 4/22/14, 4/1/14, 3/25/14, 3/18/14, 3/4/14, 2/25/14, 2/18/14, 2/11/14, and 2/3/14.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counseling services that are provided according to the individual treatment plan will be documented correctly. If for some reason there is a discrepancy in this, proper documentation will be noted explaining the reason behind this.
The C.E.O., as well as any future contracted staff will be responsible for carrying this out.
This correction will occur immediately. |
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 client records, the facility failed to document a physician signature on treatment plans, as imposed by 55 Pa. Code Part III, in five of six client records reviewed,
The findings include:
Five client records requiring the documentation of a physician signature on treatment plans were reviewed on July 23, 2015. Treatment for all six clients is funded through the Medical Assistance program. The facility failed to obtain a physician signature on treatment plans for clients # 2, 3, 4, 5, and 6.
Client # 2 was admitted into treatment on 10/7/14 and was still active at the time of the inspection. The client's master treatment plan, dated 11/7/14, was not signed by a physician. In addition, the client's treatment plan updates, dated 1/7/15, 3/7/15, 5/7/15, and 7/7/15, were not signed by a physician.
Client # 3 was admitted into treatment on 9/29/14 and was still active at the time of the inspection. The client's master treatment plan, dated 10/29/14, was not signed by a physician. In addition, the client's treatment plan updates, dated 12/19/14, 2/28/15, 4/29/15, and 6/29/15, were not signed by a physician.
Client # 4 was admitted into treatment on 5/23/15 and was still active at the time of the inspection. The client's master treatment plan, dated 6/23/15, was not signed by a physician.
Client # 5 was admitted into treatment on 1/14/14 and was discharged on 10/1/14. The client's master treatment plan, dated 2/14/14, was not signed by a physician. In addition, the client's treatment plan updates, dated 4/14/14, 6/14/14, and 8/14/14, were not signed by a physician.
Client # 6 was admitted into treatment on 2/3/14 and was discharged on 8/15/14. The client's master treatment plan, dated 3/3/14, was not signed by a physician. In addition, the client's treatment plan updates, dated 5/3/14 and 7/3/14, were not signed by a physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physician signature on all treatment plans for medical assistance clients will occur.
The C.E.O. will be responsible for seeing that this is carried out.
This correction will occur immediately. |