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 - 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill log, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. Fire drill records were reviewed from March 2025 through March 2026. No fire drills were conducted during sleeping hours within the review period.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Effective immediately, onsite staff will conduct fire drills during sleeping hour on a quarterly (every 3months) basis along with other required fire drills.
A fire drill schedule will be established by the program director to ensure annual compliance moving forward.
The conducting of drills will be the responsibility of on-site staff, and the ensuring of compliance will be the responsibility of the facility director.
New schedule and records of completed fire drills will be kept in on-site fire drill log. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative information, the facility failed to provide documentation of inspection of storage areas that ensures compliance with state and federal regulations and program policy.The facility ' s policy and procedure manual states the inspection of storage areas should be done quarterly. No inspection logs were provided during inspection.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Beginning immediately, our collaborating pharmacy will conduct quarterly inspection of medication storage. The first will be 4/10/26 and continue thereafter every 84 days.
We will store results on site in a binder and digitally in medication inspection logs.
Ensuring 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 one 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 #5 was admitted to the inpatient level of care on July 9, 2025 and was discharged December 29, 2025. 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
The facility director along with clinical managers will establish an AMA discharge checklist to include:
ROI verification, emergency contact notification (if permitted), and proper documentation of attempts and outcome.
Additionally, additional training will be provided to staff involved in discharge processes to ensure understanding of the requirements and usage of the checklist. Establishment of checklist and staff training to be completed by 6/19/2026.
Ensuring of compliance will be the responsibility of the program director. |