INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on March 16-20 and 23-25, 2026 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 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of staff records, the facility failed to ensure counselors meet qualifications in one of six applicable records.
Staff #6 was hired to the position of counselor on April 13, 2025 and was in this position at the time of review. Staff #6 does not possess a qualifying degree or certification for the position of counselor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #6 was in the position of counselor. Since his hire date of 4/13/25, we have conducted and recorded weekly supervision with the clinical supervisor and monitored his work closely.
Effective immediately, Staff #6 will be changed to the position of counselor assistant, for which he does meet requirements. We will continue weekly supervision with clinical manager and close clinical supervision of caseload.
Additionally, Staff #6 will work towards acquiring a CADC certification.
Compliance will be the responsibility of the program director. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify a client ' s emergency contact when discharged against medical advice in one of two applicable record.
Facility policy and procedure states that emergency contacts will be notified no later than 12 hours after a client is discharged against medical advice.
Client #12 was admitted to the inpatient level of care on February 17, 2026 and was discharged March 1, 2026. There was no indication that the client ' s emergency contact was notified when they were discharged against medical advice.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective 4/27/26, all staff will be training will be refreshed to ensure compliance here.
An AMA discharge checklist will also be established to include ROI verification, emergency contact notification if permitted, and proper documentation of attempts to contact and outcome in the chart.
Compliance will be the responsibility of the clinical supervisor and program director. |