INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22, 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 - 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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709.28 (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 from the client for the disclosure of information that contained whether the client was offered a copy of the client consent in one of fourteen records reviewed.
Client # 8 was admitted to the outpatient level of care on March 2, 2023 and was discharged on March 9, 2023. There was an informed and voluntary consent form for an employer signed by the client on February 15, 2023, that did not document whether the client was offered a copy of the consent 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. |
709.33 (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 reviewed.
Client # 8 was admitted to the outpatient level of care on March 2, 2023 and was discharged on March 9, 2023. There was no documentation that the facility notified the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapist was reeducated on insuring that documentation of the client being notified in writing of a decision to involuntarily terminate their treatment must be included in the clients record following the involuntary discharge. Office Manager will conduct record audits upon discharge of clients to insure the timely completion of required documentation including involuntary discharge notification was sent to the client. Outpatient Manager will conduct monthly audits to insure the timely completion of required documentation and will provide ongoing training and clinical support to therapist. Senior Outpatient Manager has already addressed this deficiency and has implemented POC. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure counseling was provided to a client on a regular and scheduled basis that included individual counseling, at least twice weekly in two of six applicable records reviewed.
Client #10 was admitted to the partial hospitalization level of care on January 4, 2023 and discharged on February 28, 2023. Client #10 only had documentation of one individual counseling session for the weeks of January 22, 2023- January 28, 2023, January 29, 2023 - February 4, 2023, and February 12, 2023 - February 18, 2023. There were no individual counseling sessions documented the week of February 19, 2023-February 25, 2023.
Client #12 was admitted to the partial hospitalization level of care on February 27, 2023 and was current at the time of the inspection. Client #5 only had documentation of one individual counseling session for the week of February 26, 2023 - March 4, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Reeducated Therapist of partial hospitalization requirements of providing two individual sessions weekly as well as group sessions two times weekly. Reeducated Therapist on accurate and timely documentation of all services provided as well as accurately reflecting on Record of Service. Reeducated Therapist that Treatment Plans must indicate an accurate description of the services and frequency of said services per level of care. Office Manager will conduct bi-weekly audits to insure all necessary services are provided and documented. Outpatient Manager will conduct monthly audit to insure all necessary services are accurately indicated in Treatment Plan and are being provided and reflected with accurate and timely documentation. Senior Outpatient Manager has already addressed this deficiency and implemented corrective actions. |