INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 21, 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 Women 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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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of facility records and staff interview, the facility failed to file a written unusual incident report with the Department within 3 business days following an event at the facility requiring the presence of fire personnel.
A fire drill log dated January 25, 2024 indicated the fire alarm was set off during a fire drill and fire personnel responded to the facility. An unusual incident for the event should have been filed with the Department no later than January 28, 2024. No unusual incident for the event had been filed with the Department as of the time of review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 20, 2024, the Regional Director of HIM and Compliance updated the Incident Notification & Risk Management Policy & Procedure.
The Clinical Supervisor will complete the Unusual Incident Report Form within three business days of the unusual incident.
All applicable staff will be trained on the updated Incident Notification & Risk Management Policy & Procedure.
The Clinical Supervisor will maintain the reports in a binder with the corresponding confirmation for each report.
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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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 a record of services provided in five of seven records.
Client #1 was admitted to the inpatient level of care on October 18, 2023 and was active at the time of review. Client #1 ' s record contained group notes for the dates of January 24 and January 18, 2024. These sessions did not appear on the record of service.
Client #2 was admitted to the inpatient level of care on November 1, 2023 and was active at the time of review. Client #2 ' s record contained an individual note dated January 30, 2024 and a group note dated January 31, 2024. These sessions did not appear on the record of service.
Client #3 was admitted to the inpatient level of care on September 14, 2023 and was active at the time of review. Client #3 ' s record contained group notes for January 17 and January 18, 2024. These sessions did not appear on the record of service.
Client #4 was admitted to the inpatient level of care on April 20, 2023 and was discharged December 8, 2023. Client #4 ' s record contained group notes for November 16, 2023 and December 7, 2023. These sessions did not appear on the record of service.
Client #5 was admitted to the inpatient level of care on June 12, 2023 and was discharged November 20, 2023. Client #5 ' s record contained individual notes for November 2 and November 15, 2023, as well as a group note for November 16, 2023. These sessions did not appear on the record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director and Clinical manager met with clinical team to review Records of Services (ROS)procedures on 3-5-23. Therapist will review client's charts ensuring that ROS are completed after each group. Overnight clinical staff will review charts daily ensuring that ROS's are completed and correct. The clinical manager will conduct monthly audits of charts including reviewing of record of services. |
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 four of four 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 April 20, 2023 and was discharged December 8, 2023. Follow-up information was due no later than January 8, 2024. 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 June 12, 2023 and was discharged November 20, 2023. Follow-up information was due no later than December 20, 2023. The client record did not contain any follow-up information at the time of review.
Client # 6 was admitted to the inpatient level of care on August 28, 2023 and was discharged September 2, 2023. Follow-up information was due no later than October 2, 2023. The client record did not contain any follow-up information at the time of review.
Client #7 was admitted to the inpatient level of care on November 14, 2023 and was discharged November 25, 2023. Follow-up information was due no later than December 25, 2023. 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. |