INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal conducted on March 16-20 and 23-25, 2026 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:
|
Plan of Correction
|
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
Based on a review of administrative information, the facility failed to provide documentation of inspection of storage areas that ensures compliance with state and federal regulations and program policy.The facility ' s policy and procedure manual states the inspection of storage areas should be done quarterly. No inspection logs were provided during inspection.This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Effective immediately, the pharmacy with which we partner will conduct quarterly medication inspections. The first took place on 4/10. The inspections will continue to be conducted as such every 84 days.
The results will be kept both digitally and in an onsite medication inspection log. Ensuring of compliance will be the responsibility of the facility director. |