INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on February 27, 2025 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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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 one applicable records.
Client #7 was admitted to the inpatient level of care on October 7, 2024 and was discharged December 11, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with 709.33 (a) related to notification of involuntary termination from treatment at the project. Based on these findings, all applicable staff will be re-trained in the involuntary discharge workflow. The clinical manager will review all discharges to assure that discharge paperwork adheres to the approved workflow. The clinical manager will conduct weekly chart audits for one month and monthly thereafter to ensure compliance. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan, in seven of seven applicable records.
There was no documentation on any treatment plan that work done by the client while in residential treatment was an integral part of treatment in all records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.53 (a) related to work as treatment. The Project Director and the Clinical Manager and Director will provide education to all staff regarding inclusion of the therapeutic value of work in treatment planning and collaborate with each patient to assure that the work is in line with their treatment goals. Each treatment plan date will be reviewed to ensure compliance with the addition of work as an integral component of their treatment and rehabilitation process. The Clinical Manager will review and sign off on all treatment plans in the EHR. The Clinical Manager will conduct weekly chart audits for two months and monthly thereafter to ensure compliance. The Project Director will review these audits with the Clinical Manager in weekly supervision. |