INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21, 2014 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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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 upon a review of administrative documentation, the facility failed to make available to the public an annual report.
The findings include:
On July 7, 2014, the facility's administrative documentation was reviewed for the July 21, 2014 inspection. The facility was required to make the annual report available to the public.
The 2013 annual report was provided and reviewed during the inspection; however, the facility failed to provide verification of how the annual report was made available to the public.
This is a repeat citation from the 08/29/2013 licensing renewal inspection.
The findings were confirmed by the Project Director during an interview conducted on July 21, 2014.
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Plan of Correction
The project director of the facility will make available to the public notification that the annual report is ready for review. A statement will be submitted to the local newspaper upon the completion of the annual report. This will be done on a yearly basis.
This will be completed within 1 month of todays date (09/18/2014) |
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 assure that counseling services were provided according to the individual treatment and rehabilitation plan in two of six client records reviewed.
The findings included:
Six client records requiring the documentation of the provision of services in accordance with those specified in the treatment plan were reviewed on July 21, 2014. The facility failed to provide counseling services as stated in the treatment and rehabilitation plan in client record #'s 1 and 3.
Client #1 was admitted to treatment on 07/06/2013 and was discharged on 10/01/2013. An individual treatment and rehabilitation plan was developed with the client on 07/06/2013 and the plan stated that the client would be provided individual outpatient counseling on a one time per week basis. The client did not have a counseling session during the weeks of 07/08/2013, 08/05/2013, and 09/02/2013.
Client #3 was admitted to treatment on 02/03/2014 and was still an active client at time of the inspection. An individual treatment and rehabilitation plan was developed with the client on 02/03/2014 and the plan stated that the client would be provided individual outpatient counseling on a one time per week basis. The client did not have a counseling session during the weeks of 04/15/2014, 04/29/2014, 06/10/2014, 06/24/2014, and 07/15/2014.
The Project Director confirmed the findings.
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Plan of Correction
The facility will assure that counseling services will be provided according to the individual treatment and rehabilitation plan.
This will be accomplished by noting that dates of sessions match with the designated treatment plan. If a session does not occur according to the treatment plan, documentation will be provided as to why this has occurred.
This will be done immediately, and will be accomplished by the C.E.O./Therapist of the facility.
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