INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 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 - Wexford 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 contained in two of fourteen client records reviewed.
Client #2 was admitted to the partial hospitalization level of care on February 27, 2023 and was still current at the time of the inspection. The client record did not contain an informed and voluntary consent from the client for the disclosure of information for the client ' s funder. The facility staff confirmed billing had been occurring since admission.
Client #11 was admitted to the outpatient level of care on August 9, 2022 and discharged on December 21, 2022. Client #11 had a progress note in the record documenting a family session that occurred on November 2, 2022, with a parent; however, there was not an informed and voluntary consent signed by the client for the disclosure of information for that parent located in the client record.
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, the date, event or condition upon which the consent will expire 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. |
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 for the disclosure of information form that included whether the client was offered a copy or not in two of fourteen client records reviewed.
Client #6 was admitted to the partial hospitalization level of care on September 9, 2022 and discharged on November 23, 2022. Client #6 had an informed and voluntary consent for the disclosure of information form for both a family member and a funder that was signed and dated by the client on September 28, 2022, that did not include whether a copy was offered to the client or not.
Client #12 was admitted to the outpatient level of care on July 13, 2022 and discharged on September 20, 2022. Client #12 had an informed and voluntary consent for the disclosure of information form for a family member that was signed and dated by the client on June 22, 2022, that did not include whether a copy was offered to the client or not.
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, the date, event or condition upon which the consent will expire 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. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection on March 20, 2023, the facility failed to display the hours of project operation conspicuously to the general public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A sign displaying the facility day/hours of operation and phone number was fixed in a location at the main entrance of the facility, which is viewable to the general public. All facility staff were reeducated on ensuring that this sign is visible and accurate of programs operation and contact information. Senior Outpatient Manager will conduct monthly safety audits, which will include insuring facility hours of operation and phone number are visible to the general public. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection on March 20, 2023, the facility failed to display a telephone number conspicuously to the general public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A sign displaying the facility day/hours of operation and phone number was fixed in a location at the main entrance of the facility, which is viewable to the general public. All facility staff were reeducated on ensuring that this sign is visible and accurate of programs operation and contact information. Senior Outpatient Manager will conduct monthly safety audits, which will include insuring facility hours of operation and phone number are visible to the general public. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection on March 20, 2023, the facility failed to display the hours of project operation conspicuously to the general public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A sign displaying the facility day/hours of operation and phone number was fixed in a location at the main entrance of the facility, which is viewable to the general public. All facility staff were reeducated on ensuring that this sign is visible and accurate of programs operation and contact information. Senior Outpatient Manager will conduct monthly safety audits, which will include insuring facility hours of operation and phone number are visible to the general public. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection on March 20, 2023, the facility failed to display a telephone number conspicuously to the general public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A sign displaying the facility day/hours of operation and phone number was fixed in a location at the main entrance of the facility, which is viewable to the general public. All facility staff were reeducated on ensuring that this sign is visible and accurate of programs operation and contact information. Senior Outpatient Manager will conduct monthly safety audits, which will include insuring facility hours of operation and phone number are visible to the general public. |