INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20, 2024 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 - The Lighthouse For Men 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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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents, the project failed to document an annual financial audit for the fiscal year ending June 30, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Chief Financial Officer shall obtain a copy of the most recent financial audit from the CPA Consulting Firm (MaherDuessel).
The Project Director shall ensure that the annual financial audit is available during the annual DDAP licensing inspections.
Upon notification of future DDAP licensing inspections, the Project Director will request a copy of the most recent financial audit so it will be available for review during the inspection.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure there is a complete client record which includes follow-up information in two of two records.
Facility policy and procedure states follow-up information is to be acquired 30 days post discharge.
Client # 4 was admitted to the inpatient level of care on August 1, 2023 and was discharged August 15, 2023. Follow-up information was due no later than September 15, 2023. The client record did not contain any follow-up information at the time of review.
Client #5 was admitted to the inpatient level of care on December 13, 2023 and was discharged January 17, 2024. Follow-up information was due no later than February 17, 2024. The client record did not contain any follow-up information at the time of review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Consent for Staff Follow-Up and Post Discharge Follow-Up will be built into our Electronic Health Record (Sigmund). Until this change is made (5/1/24), the Clinical Supervisor will review the Consent for Staff Follow-Up paper form with all active patients and new admissions. The Clinical Supervisor will complete the follow-up calls within 30 days of discharge and complete the Post Discharge Follow-Up paper form. The program Discharge Log shall serve as a Tracking Sheet for Post Discharge Follow-Up calls are being completed. The Clinical Manager will conduct weekly Post-Discharge Follow-Up audits for one month and monthly thereafter to ensure compliance. |