INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18, 2009 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 and a plan of correction is due on September 18, 2009.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the employee personnel and training files during the annual onsite inspection of August 19, 2009, the facility failed to ensure that each employee had the required mandatory communicable disease training documented.
The findings included:
Employee # 1 had both HIV/AIDS and TB/STD training documented, however, the required TB/STD training was obtained via a correspondence course (L.A.S.T.) in February 1999. Distance learning/correspondence training obtained prior to January 1, 2009 may not be counted (see the licensing alert entitled " Satisfaction of Staff Training Requirements" issued January 2009) . This employee does not have documentation of an acceptable TB/STD training.
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Plan of Correction
All employees will have the required mandatory communicable disease training documented.
This will take place within the next 3-6 months |
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
Based on the physical plant inspection during the onsite licensing inspection of August 19, 2009, the facility failed to ensure that each bathroom was ventilated by an operable fan or window.
The findings included:
At the time of the physical plant inspection at 9 A.M. on August 19, 2009, the one bathroom in the facility was inspected. At that time the exhaust fan was inoperable . The bathroom does not have a window.
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Plan of Correction
The C.E.O., Jacqueline Costello will ensure that the bathroom will be properly ventilated by a working exhaust fan.
This will take place within the next 3 months. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of employee personnel and training records and an interview with the Project Director during the onsite licensing inspection of August 19, 2009, the facility failed to ensure that each employee had documentation of training in the use of fire extinguishers.
The findings included:
At the time of the annual inspection one employee record was reviewed . Each employee is required to have documented training of fire extinguisher operation. No such documentation was filed in personnel record # 1.
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Plan of Correction
The C.E.O. will make sure that everyone employed within this facility is properly trained in the operation of a fire extinguisher. This training will be given by a local fire department. Once this takes place proper documentation will occur.
THis will take place within the next 3 months. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of the agency manual and other administrative materials during the annual onsite licensing inspection of August 19, 2009, the facility failed to document an annual audit.
The findings included:
The agency manual and administrative materials were reviewed during the onsite inspection. No documentation of a fiscal audit for 2008 was presented at that time.
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Plan of Correction
The C.E.O. will be filing a request for exception of this citation.
If this is not granted the C.E.O. will wnsure that a proper audit be completed within the next 6 months. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the agency policy and procedure manual during the annual onsite licensing inspection of August 19, 2009 , the facility failed to document a confidentiality policy referencing "duty to warn" issues which is compliant with the regulations at 42 C. F. R. Part 2, Subpart E, Subsection 2.63 (a)(1).
The findings included:
The confidentiality policy documented in the agency manual stated that "...If the client is presenting homicidal thoughts, the client's primary therapist will inform the client of their obligation to inform the appropriate person(s) in danger." This policy constitutes a duty to warn. Currently there is "Duty to Warn" case law in Pennsylvania, Emerich vs PHMC, does speak to a duty to warn for behavioral health treatment, but this does not supersede the regulations at 42 C. F. R. Part 2, Subpart E, Subsection 2.63(a)(1) which requires that the facility obtain a court order prior to giving the warning.
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Plan of Correction
C.E.O. will corect current confidentiality policy in re. to duty to warn. The plan will correctly identify the proper procedure that needs to be followed with all D/A clients.
This will be documented in manual.
This will take place within the next 3-6 months. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on the review of client record during the annual onsite licensing inspection of August 19, 2009, the facility failed to document progress notes which contained data, assessment and plan components as required. Plan components were incomplete in four of four client records.
The findings included:
Four client records were reviewed during the annual onsite inspection. Each record was required to document progress notes which contained a plan component that reflected the counselor's actions to be taken in light of the evaluation and indicated the direction of treatment and included action steps, counselor plan(s) and client assignments or tasks. In four of four records reviewed ( #1, 2, 3, and 4 ) the plan component stated the the client will "..abide by the treatment plan and will be seen again on____." This does not rise to the level of a plan component for the progress note.
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Plan of Correction
All counselors will follow the correct format, data, assessment, plan, for all progress notes on clients.
The plan will specifically identify the steps the client will take in meetint the treatment objectives identified.
THis will take place within the next month. |
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 the review of client records during the annual onsite licensing inspection of August 19, 2009, the facility failed to document physician signatures on treatment plans and treatment plan updates in accordance with 55 Pa. Code Part III (relating to the Medical Assistance manual) in two of two client records.
The findings included:
Four client records were reviewed during the annual onsite licensing inspection . Two of these records were required to have physician signatures on the treatment plans and treatment plan updates because they were funded from Medical Assistance/ Healthchoices funding streams. Physician signatures were missing from the treatment plans and treatment plan updates documented in client records # 1 & 2.
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Plan of Correction
The C.E.O. will ensure that all clients having Medical Assistance will have the treatment plans, updates, and consults signed by the physician.
This will take place within the next month. |