INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4-5, 2024 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 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 facility records, the facility failed to ensure that a fire drill was conducted during sleeping hours at least every six months.
Facility fire drill logs between April 2023 through February 2024 were reviewed.
Facility fire drill logs documented that a fire drill occurred on July 15, 2023 at 6:35 AM, which was during facility sleeping hours. The next fire drill during sleeping hours was to be conducted no later than January 31, 2024. No further fire drills were documented as occurring during sleeping hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1)Implementation of fire drills once a
month by the clinical manager, program director, security personnel, or maintenance.
2)Implementation of fire drills each quarter will include all 3 shifts. The day 7AM-3PM, evening 3PM-11PM, and overnight shifts 11PM-7AM
Health & Safety inspections will be
conducted for monthly and quarterly fire drills. Quarterly fire drills will ensure that all 3 shifts are implemented. Health & Safety Inspection results will be reported to the monthly Health & Safety Committee. Program director is responsible for for ensuring that all fire drills are submitted into our internal reporting system, Navex, and given to Health and Safety Committee. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents, the project failed to document an annual financial audit for the fiscal year ending June 30, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Chief Financial Officer shall obtain a copy of the most recent financial audit from the CPA Consulting Firm (MaherDuessel).
The Project Director shall ensure that the annual financial audit is available during the annual DDAP licensing inspections.
Upon notification of future DDAP licensing inspections, the Project Director will request a copy of the most recent financial audit so it will be available for review during the inspection.
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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 ensure that a copy of a client consent was offered to the client in two of fourteen records.
Client #1 was admitted to the detox level of care on March 1, 2024 and was active at the time of review. Client #1 ' s record contained a client consent form signed March 1, 2024. The form had boxes to indicate whether a copy was offered to the client, however no boxes were marked.
Client #2 was admitted to the detox level of care on March 2, 2024 and was active at the time of review. Client #2 ' s record contained a client consent form signed March 3, 2024. The form had boxes to indicate whether a copy was offered to the client, however no boxes were marked.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 709.28 (d) related to confidentiality of a client consent to be offered to the client and a copy maintained in the record. Based on these findings the Consent for the Release of Information will be built into our Electronic Health Record (Sigmund). The electronic Release of Information Consent Form is equipped with Copy Accepted and Copy Refused force field data elements that must be completed by the client.
Until this change is made (5/1/24), the Regional Director of Health Information will retrain all applicable staff on the completion of the paper Consent for the Release of Information form ensuring the patient checks either the Copy Accepted or Copy Refused boxes.
The Supervisor of Health Information Management will conduct monthly chart audits to ensure all consent forms are completed correctly. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to document written acknowledgement by clients that they have been notified of their client rights in eleven of eleven applicable records.
The facility was unable to provide documentation that clients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 13 had been notified of their client rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.30 Client Rights
The facility failed to comply with 709.30 related to client rights. Based on these findings the Consent for Evaluation and Treatment will be built into our Electronic Health Record (Sigmund). The electronic Consent for Evaluation and Treatment is equipped with Client Rights. Until this change is made (5/1/24), the paper Consent for Evaluation and Treatment will be review with all clients during the client admission registration process. The Regional Director of Health Information will retrain all applicable staff on the completion of the paper Consent for Evaluation and Treatment that includes Client Rights. The Supervisor of Health Information Management will conduct monthly chart audits to ensure all new admissions have the completed Consent for Evaluation and Treatment consent form that includes Client Rights:
(1) A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
(3) Clients have the right to inspect their own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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709.63(a)(5) LICENSURE Record of Services
709.63. 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:
(5) Record of services provided.
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Observations
Based on a review of client records, the facility failed to ensure there was a record of services provided in seven of seven detoxification records.
Client #1, 2, 3, 4, 5, 6, and 7 record ' s did not contain a record of services provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.53(a)(3) Records of Service:
The Record of Service will be built into our Electronic Health Record (Sigmund). Until this change is made (5/1/24), the Program Director and Clinical Team will re-instate the paper Record of Service form to be completed after each Individual and Group Service. All applicable staff will be trained on the Record of Service form and workflow. The Clinical Manager will conduct weekly Record of Service audits for one month and monthly thereafter to ensure compliance.
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to ensure there was a record of services provided in seven of seven residential treatment and rehab records.
Client #8, 9, 10, 11, 12, 13, and 14 record ' s did not contain a record of services provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.53(a)(3) Records of Service:
The Record of Service will be built into our Electronic Health Record (Sigmund). Until this change is made (5/1/24), the Program Director and Clinical Team will re-instate the paper Record of Service form to be completed after each Individual and Group Service. All applicable staff will be trained on the Record of Service form and workflow. The Clinical Manager will conduct weekly Record of Service audits for one month and monthly thereafter to ensure compliance.
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709.53(a)(11) LICENSURE Follow-up information
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:
(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 three of three records.
Facility policy and procedure states that follow-up information is to be acquired 30 days post discharge.
Client # 11 was admitted to the inpatient level of care on November 3, 2023 and was discharged November 20, 2023. Follow-up information was due no later than December 20, 2023. The client record did not contain any follow-up information at the time of review.
Client #12 was admitted to the inpatient level of care on December 11, 2023 and was discharged January 4, 2024. Follow-up information was due no later than February 4, 2024. The client record did not contain any follow-up information at the time of review.
Client #14 was admitted to the inpatient level of care on December 4, 2023 and was discharged December 20, 2023. Follow-up information was due no later than January 20, 2024. 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
709.53(a)(11) Follow-up information:
The Consent for Staff Follow-Up and Post Discharge Follow-Up will be built into our Electronic Health Record (Sigmund). Until this change is made (5/1/24), the Clinical Supervisor will review the Consent for Staff Follow-Up paper form with all active patients and new admissions. The Clinical Supervisor will complete the follow-up calls within 30 days of discharge and complete the Post Discharge Follow-Up paper form. The program Discharge Log shall serve as a Tracking Sheet for Post Discharge Follow-Up calls are being completed. The Clinical Manager will conduct weekly Post-Discharge Follow-Up audits for one month and monthly thereafter to ensure compliance.
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