INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on February 25, 2025 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of two applicable records.
Client #2 was admitted to the inpatient level of care on September 3, 2024 and was discharged December 30, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 709.33 (a) related to notification of involuntary termination from treatment at the project. Based on these findings, all applicable staff will be re-trained in the involuntary discharge workflow. The clinical manager will review all discharges to assure that discharge paperwork adheres to the approved workflow. The clinical manager will conduct weekly chart audits for one month and monthly thereafter to ensure compliance. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in six of six applicable records.
Client #2 was admitted to the inpatient level of care on September 3, 2024 and was discharged December 30, 2024. Client #2 ' s record contained a treatment plan dated October 3, 2024. A treatment plan update was due no later than November 3, 2024. No further treatment plan updates were completed prior to Client #2 ' s discharge.
Client #3 was admitted to the inpatient level of care on June 11, 2024 and was discharged January 31, 2025. Client #3 ' s record contained a treatment plan dated August 21, 2024. A treatment plan update was due no later than September 21, 2024. The next treatment plan update for Client #3 was completed November 21, 2024.The next treatment plan update for Client #3 was due no later than December 21, 2024. No further treatment plan updates were completed prior to Client #3 ' s discharge.
Client #4 was admitted to the inpatient level of care on June 17, 2024 and was discharged December 9, 2024. Client #4 ' s record contained a treatment plan dated October 31, 2024. A treatment plan update was due no later than December 1, 2024. The next treatment plan update for Client #4 was completed December 5, 2024.
Client #5 was admitted to the inpatient level of care on December 16, 2024 and was active at the time of review. Client #5 ' s record contained a treatment plan dated January 14, 2025. A treatment plan update was due no later than February 14, 2025. The next treatment plan update for Client #5 was completed February 18, 2025.
Client #6 was admitted to the inpatient level of care on October 7, 2024 and was active at the time of review. Client #6 ' s record contained a treatment plan dated January 16, 2025. A treatment plan update was due no later than February 16, 2025. The next treatment plan update for Client #6 was completed February 18, 2025.
Client #7 was admitted to the inpatient level of care on November 15, 2024 and was active at the time of review. Client #7 ' s record contained a treatment plan dated November 20, 2024. A treatment plan update was due no later than December 20, 2024. The next treatment plan update for Client #7 was completed February 24, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.52 (b) Related to treatment and rehabilitation services. The Clinical Manager will provide weekly supervision to all counselors to assure that treatment plans are completed. All treatment plans will be completed a minimum of one day prior to the last day of the current treatment plans to ensure that there is no lapse in treatment planning and patient care. Each treatment plan date will be reviewed to ensure compliance with timely treatment planning. The Clinical Manager will sign off on treatment plans in the EHR at completion. The clinical manager will conduct weekly chart audits for two months and monthly thereafter to ensure compliance. The Project Director will review these audits with the Clinical Manager in weekly supervision.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan, in seven of seven applicable records.
There was no documentation on any treatment plan that work done by the client while in residential treatment was an integral part of treatment in all records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.53 (a) related to work as treatment. The Project Director and the Clinical Manager and Director will provide education to all staff regarding inclusion of the therapeutic value of work in treatment planning and collaborate with each patient to assure that the work is in line with their treatment goals. Each treatment plan date will be reviewed to ensure compliance with the addition of work as an integral component of their treatment and rehabilitation process. The Clinical Manager will review and sign off on all treatment plans in the EHR. The Clinical Manager will conduct weekly chart audits for two months and monthly thereafter to ensure compliance. The Project Director will review these audits with the Clinical Manager in weekly supervision. |