INITIAL COMMENTS
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This report is a result of an on-site licensure renewal. The physical plant inspection was conducted on February 23, 2023, and client record review was conducted on March 6 & 7, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Greenbriar Treatment Center - South Hills 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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709.28 (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 obtain an informed and voluntary consent from the client for the disclosure of information in one of thirteen records reviewed.
Client #1 was admitted to the partial hospitalization level of care on September 26, 2022 and was discharged on October 3, 2022. Client #1 had a letter to a physician ' s office faxed on August 30, 2022, however there was no informed and voluntary consent to disclose information located in the record for the physician ' s office.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Evaluators were reeducated to ensure informed and voluntary consent from the client is completed prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Therapist/Office Manager were reeducated to fully complete a new informed and voluntary consent from the client for any additional Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others during the course of treatment ensuring the purpose of the consent. Office Manager will review all informed consents to verify the completion of informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audits to verify of accurate and complete informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others are completed fully. Outpatient Manager will conduct monthly audits of records to insure consents are accurate and complete as well as provide continued training on this matter. This deficiency was already corrected and implemented by Senior Outpatient Manager. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information that included the specific information to be disclosed in one of thirteen records reviewed.
Client #2 was admitted to the partial hospitalization level of care on July 7, 2022 and discharged on August 16, 2022. Client #2 had an informed and voluntary consent for a clinic signed and dated July 1, 2022, that did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Evaluators were reeducated to ensure informed and voluntary consent from the client is completed fully including the purpose of the consent and specific information to be disclosed prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Therapist/Office Manager were reeducated to fully complete a new informed and voluntary consent from the client for any additional Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others during the course of treatment ensuring the purpose of the consent. Office Manager will review all informed consents to verify the completion of informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audits to verify of accurate and complete informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others are completed fully including the purpose of the consent and specific information to be disclosed. Outpatient Manager will conduct monthly audit to verify the accurate completion of consents and provide ongoing training of this requirement. This deficiency was already corrected and implemented by Senior Outpatient Manager. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information that contained the purpose of disclosure in two of thirteen records reviewed.
Client #1 was admitted to the partial hospitalization level of care on September 26, 2022 and was discharged on October 3, 2022. Client #1 had an informed and voluntary consent for a family member signed and dated August 15, 2022, that did not include the purpose of disclosure.
Client #4 was admitted to the partial hospitalization level of care on October 5, 2022 and discharged on October 31, 2022. Client #4 had an informed and voluntary consent for a family member signed and dated October 3, 2022, that did not include the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Evaluators were reeducated to ensure informed and voluntary consent from the client is completed fully including the purpose of the consent and specific information to be disclosed prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Therapist/Office Manager were reeducated to fully complete a new informed and voluntary consent from the client for any additional Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others during the course of treatment ensuring the purpose of the consent. Office Manager will review all informed consents to verify the completion of informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audits to verify of accurate and complete informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others are completed fully including the purpose of the consent and specific information to be disclosed. Outpatient Manager will conduct monthly audit to verify the accurate completion of consents and provide ongoing training of this requirement. This deficiency was already corrected and implemented by Senior Outpatient Manager. |
709.28 (c) (4) 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. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information that included the dated signature of the client in one of thirteen records reviewed.
Client #10 was admitted to the outpatient level of care on September 28, 2022 and discharged on October 25, 2022. Client #10 had an informed and voluntary consent to disclose information form for an employee assistance program that was signed by a witness on September 21, 2022 but did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Evaluators were reeducated to ensure informed and voluntary consent from the client is completed fully including the purpose of the consent, specific information to be disclosed and that the consents are signed and dated by both the client and witness prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Therapist/Office Manager were reeducated to fully complete a new informed and voluntary consent from the client for any additional Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others during the course of treatment ensuring the purpose of the consent. Office Manager will review all informed consents to verify the completion of informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audits to verify of accurate and complete informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others are completed fully including the purpose of the consent, specific information to be disclosed and that the consents are signed and dated by both the client and witness. Outpatient Manager will conduct monthly audit to verify the accurate completion of consents and provide ongoing training of this requirement. This deficiency was already corrected and implemented by Senior Outpatient Manager. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information that included whether the client was offered a copy of the consent in ten of thirteen records reviewed.
Client #2 was admitted to the partial hospitalization level of care on July 7, 2022 and discharged on August 16, 2022. Client #2 had an informed and voluntary consent to disclose information form for a family member that was signed and dated July 1, 2022, that did not include whether a copy of the consent was offered to the client.
Client #3 was admitted to the partial hospitalization level of care on July 19, 2022 and discharged on September 15, 2022. Client #3 had an informed and voluntary consent to disclose information form for a family member and a physician that were signed and dated July 13, 2022, that did not include whether a copy of the consent was offered to the client.
Client #4 was admitted to the partial hospitalization level of care on October 5, 2022 and discharged on October 31, 2022. Client #4 had an informed and voluntary consent to disclose information form for a family member and a hospital that were signed and dated October 3, 2022, that did not include whether a copy of the consent was offered to the client.
Client #5 was admitted to the partial hospitalization level of care on September 27, 2022 and discharged on December 5, 2022. Client #5 had an informed and voluntary consent to disclose information form for a family member and a funder that were signed and dated September 21, 2022, that did not include whether a copy of the consent was offered to the client.
Client #6 was admitted to the partial hospitalization level of care on September 26, 2022 and discharged on December 13, 2022. Client #6 had an informed and voluntary consent to disclose information form for a family member, a hospital, a physician ' s office, an insurance company and an employee assistance program that were signed and dated September 21, 2022, that did not include whether a copy of the consent was offered to the client.
Client #7 was admitted to the partial hospitalization level of care on November 3, 2022 and discharged on December 29, 2022. Client #7 had an informed and voluntary consent to disclose information form for a funder that was signed and dated October 19, 2022 and a family member that was signed and dated November 2, 2022, that did not include whether a copy of the consent was offered to the client.
Client #10 was admitted to the outpatient level of care on September 28, 2022 and discharged on October 25, 2022. Client #10 had an informed and voluntary consent to disclose information form for a family member and a funder that were signed and dated September 27, 2022, that did not include whether a copy of the consent was offered to the client.
Client #11 was admitted to the outpatient level of care on August 18, 2022 and discharged on October 13, 2022. Client #11 had an informed and voluntary consent to disclose information form for a friend and government agency that were signed and dated August 17, 2022, that did not include whether a copy of the consent was offered to the client.
Client #12 was admitted to the outpatient level of care on October 3, 2022 and discharged on December 13, 2022. Client #12 had an informed and voluntary consent to disclose information form for a family member and a funder that were signed and dated September 27, 2022, that did not include whether a copy of the consent was offered to the client.
Client #13 was admitted to the outpatient level of care on July 11, 2022 and discharged on September 1, 2022. Client #13 had an informed and voluntary consent to disclose information form for a medication management facility that was signed and dated July 14, 2022, that did not include whether a copy of the consent was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Evaluators were reeducated to ensure informed and voluntary consent from the client is completed fully including the purpose of the consent, specific information to be disclosed, signed and dated by client and witness and clearly indicate that a copy of the consent was offered to the client prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Therapist/Office Manager were reeducated to fully complete a new informed and voluntary consent from the client for any additional Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others during the course of treatment ensuring the purpose of the consent. Office Manager will review all informed consents to verify the completion of informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audits to verify of accurate and complete informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others are completed fully including the purpose of the consent, specific information to be disclosed, signed and dated by client and witness and clearly indicate that a copy of the consent was offered to the client prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audit to verify the accurate completion of consents and provide ongoing training of this requirement. This deficiency was already corrected and implemented by Senior Outpatient Manager. |