INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 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 - The Lighthouse for Women 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on February 23, 2023, the facility failed to not permit heaters that are not permanently mounted or installed.
There was one space heater in the counselor ' s office in the basement that was not permanently mounted or installed and two in the counselor ' s office on the second floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/23/23, upon finding of space heaters in counselors offices was immediately removed from facility. On 3/1/23, Facility manager met with all staff and discussed no space heaters allowed in facility. Facility manager or director will conduct monthly walk thru facility ensuring that no space heaters are on premises. Facility manager will remind all staff of physical plant requirements during monthly staff meetings. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent to disclose information form that included the specific information to be disclosed in two records reviewed.
Client #1 was admitted on January 30, 2023 and was still a current client at the time of the inspection. Client#1 signed an informed and voluntary consent to disclose information form for a physician ' s office on September 14, 2022, and two separate family members on November 24, 2022, that did not include the specific information to be disclosed.
Client #2 was admitted on September 20, 2022 and was still a current client at the time of the inspection. Client #2 signed an informed and voluntary consent to disclose information form on February 8, 2023, for a friend that did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility manager met with clinical team on 3/1/23, to reviewed consents for Release of Information (ROI's). Clinical manager will review all consents ensuring that specific information being disclosed is included on consents.
Greenbriar's compliance officer will conduct random charts audit. This will assist in making sure that specific information being disclosed is included on consents. Upon completion of chart reviews by manager or compliance officer, will be discussed with director. identified staff will be required for retraining to assure all consents are appropriately completed. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent to disclose information form that included the purpose of disclosure in one record reviewed.
Client #1 was admitted on January 30, 2023 and was still a current client at the time of the inspection. Client#1 signed an informed and voluntary consent to disclose information form for a family member on October 25, 2022, that was missing the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility manager met with clinical team on 3/1/23, to reviewed consents for Release of Information (ROI's). Clinical manager reviewed consents ensuring that purpose of information is included on consents.
Greenbriar's compliance officer will conduct random charts audit. This will assist in making sure that purpose of information being disclosed is included on consents. Upon completion of chart reviews by manager or compliance officer, will be discussed with director. If consent is not appropriately completed, identified staff will be scheduled for retraining. |