INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on March 13, 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 - Monroeville 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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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 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 60 days in two of three applicable records.
Client #3 was admitted to the outpatient level of care on November 21, 2024 and was discharged February 28, 2025. Client #3 ' s record contained a treatment plan dated November 27, 2024. A treatment plan update was due no later than January 27, 2025. The next treatment plan update was completed January 29, 2025.
Client #4 was admitted to the outpatient level of care on October 3, 2024 and was discharged December 26, 2024. Client #4 ' s record contained a treatment plan dated October 8, 2024. A treatment plan update was due no later than December 8, 2024. No further treatment plan updates were completed prior to Client #4 ' s discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Regional Clinical Manager will review these findings with the therapist and re-educate the therapist on the process to complete treatment plans within the electronic health record as well as the timeline for due dates of treatment plan updates.
The Regional Clinical Manager will audit a minimum of 25% of the patient charts for the therapist over the next 6 months to ensure compliance.
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709.93(a)(11) LICENSURE Client records
709.93. 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 one of one applicable record.
Facility policy and procedure states follow-up information is to be acquired six months post discharge.
Client # 5 was admitted to the outpatient level of care on July 3, 2024 and was discharged August 29, 2024. Follow-up information was due no later than March 1, 2025. 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 Regional Clinical Manager will review these findings with the administrative support coordinator and re-educate the them on the process to complete the patient follow-up within the electronic health record as well as the timeline for due dates for the follow-up process.
The Regional Clinical Manager will audit a minimum of 25% of the patient charts for the therapist over the next 6 months to ensure compliance.
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