INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 13, 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 - New Kensington 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of facility records, the facility failed to conduct unannounced fire drills at least once a month.
Facility fire drill logs between May 2023 through February 2024 were reviewed. No fire drill log for the months of September 2023, October 2023, or November 2023 were found.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It shall be the responsibility of the Administrative Support Coordinator, under the supervision of the Program Manager to complete and record monthly unannounced Facility fire drills.
The Program Manager is responsible for monthly checks of the fire drill log. |
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 (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 client records, the facility failed to obtain an informed and voluntary consent that includes specific information to be disclosed in two of seven records.
Client #5 was admitted to the outpatient level of care on July 12, 2023 and was discharged November 2, 2023. Client #5 ' s record contained a release of information form dated July 6, 2023 that did not indicate specific information to be disclosed.
Client #6 was admitted to the outpatient level of care on August 28, 2023 and was discharged December 11, 2023. Client #6 ' s record contained three release of information forms dated August 28, 2023 that did not indicate specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 7, 2023 annual licensing inspection.
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Plan of Correction
It shall be the responsibility of the Program Manager to train program staff on the proper completion of Release of Information by April 9, 2024.
The Program Manager shall be responsible for verifying accurate completion of the releases by completing random chart supervision in 10% of the charts monthly. |