INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 7, 2010 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 August 3, 2010.
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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 staff development records and staff interview the facility director failed to meet the four hours of mandatory communicable disease training. Findings:A review of the facility directors staff development record and an interview with the facility director on July 7, 2010 revealed that the facility failed to document four hours of TB/STD training. TB/STD training was obtained by the facility director through a correspondence course in February 1999. Correspondence training obtained prior to January 1, 2009 can not be utilized for staff development compliance as outlined in Licensing Alert 1-09(Satisfaction of Staff Training Requirements, issued January 2009).
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Plan of Correction
Facility director will review information obtained from a previous training attended on TB/STD and document.
Facility director will also attempt to attend another training on TB/STD when one becomes available.
This will be accomplished wihin the next 3-6 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 survey results and an interview with the facility director, the project failed to document an annual audit of financial activities associated with the drug and alcohol services. Findings: Regulations require the project to obtain an annual audit of financial activities associated with the provision of drug and alcohol services. An interview with the facility director on July 7, 2010 confirmed that the project failed to document an annual audit for calender year 2008 and 2009.
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Plan of Correction
Facility director will complete a request to the licensing board to be exempted from this due to the fact that we are a very small counseling practice and an audit is quite expensive.
Facility director will provide current tax information in the interim regarding this, if needed.
This will be accomplished within the next 3 months. |
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 and and interview with the facility director, the project 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 four of four applicable recordsThe findings included:Seven records were reviewed during the annual licensing survey on July 7, 2010 . Four of the seven records were required to have physician signatures on the treatment plans and treatment plan updates due to Medical Assistance/ Healthchoices funding authorizations. Physician signatures were not documented on the treatment plans and treatment plan updates in the four applicable records. Record # 2. Admitted March 8, 2010. A review of the record on July 7, 2010 revealed that the facility failed to document physician signatures on the treatment plan and the treatment plan update. Record # 4. Admitted March 16, 2010. A review of the record on July 7, 2010 revealed that the facility failed to document physician signatures on the treatment plan and the treatment plan update. Record # 5. Admitted June 6, 2009 and discharged on August 10, 2009. A review of the record on July 7, 2010 revealed that the facility failed to document physician signatures on the treatment plan. Record # 7. Admitted April 29, 2009 and discharged on September 9, 2009. A review of the record on July 7, 2010 revealed that the facility failed to document physician signatures on the treatment plan and the treatment plan update.
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Plan of Correction
Facility director will obtain signiture from physician on treatment plans, and updates on all medical assistance clients.
This will be accomplished within the next 3 months. |