INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7, 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 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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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 one of eight records reviewed.
Client #5 was admitted to partial hospitalization on July 25, 2022 and discharged from outpatient on November 8, 2022. A release of information to a physician was signed on July 20, 2022, that did not indicate the specific information to be disclosed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Evaluators were reeducated to ensure informed and voluntary consent from the client is completed fully including the purpose of the consent, specific information to be disclosed, signed and dated by client and witness and clearly indicate that a copy of the consent was offered to the client prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Therapist/Office Manager were reeducated to fully complete a new informed and voluntary consent from the client for any additional Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others during the course of treatment ensuring the purpose of the consent. Office Manager will review all informed consents to verify the completion of informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audits to verify of accurate and complete informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others are completed fully including the purpose of the consent, specific information to be disclosed, signed and dated by client and witness and clearly indicate that a copy of the consent was offered to the client prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audit to verify the accurate completion of consents and provide ongoing training of this requirement. This deficiency was already corrected and implemented by Senior Outpatient Manager. |
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 client records, the facility failed to obtain an informed and voluntary consent that included the purpose of disclosure in two of eight records reviewed.
Client #1 was admitted on August 8, 2022 to partial hospitalization and discharged on September 29, 2022. A release of information to a significant other was signed on August 4, 2022, that did not indicate the purpose of disclosure.
Client #5 was admitted to partial hospitalization on July 25, 2022 and discharged from outpatient on November 8, 2022. A release of information to a family member was signed on July 20, 2022, that did not indicate the purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Evaluators were reeducated to ensure informed and voluntary consent from the client is completed fully including the purpose of the consent, specific information to be disclosed, signed and dated by client and witness and clearly indicate that a copy of the consent was offered to the client prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Therapist/Office Manager were reeducated to fully complete a new informed and voluntary consent from the client for any additional Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others during the course of treatment ensuring the purpose of the consent. Office Manager will review all informed consents to verify the completion of informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audits to verify of accurate and complete informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others are completed fully including the purpose of the consent, specific information to be disclosed, signed and dated by client and witness and clearly indicate that a copy of the consent was offered to the client prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audit to verify the accurate completion of consents and provide ongoing training of this requirement. This deficiency was already corrected and implemented by Senior Outpatient Manager. |
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 document that the client was offered a copy of an informed and voluntary consent in one of eight records reviewed.
Client #5 was admitted to partial hospitalization on July 25, 2022 and discharged from outpatient on November 8, 2022. Informed and voluntary consent to disclose information forms were signed on July 20, 2022, for a physician and another agency that did not include whether a copy was offered to the client.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Evaluators were reeducated to ensure informed and voluntary consent from the client is completed fully including the purpose of the consent, specific information to be disclosed, signed and dated by client and witness and clearly indicate that a copy of the consent was offered to the client prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Therapist/Office Manager were reeducated to fully complete a new informed and voluntary consent from the client for any additional Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others during the course of treatment ensuring the purpose of the consent. Office Manager will review all informed consents to verify the completion of informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audits to verify of accurate and complete informed and voluntary consent from the client for any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others are completed fully including the purpose of the consent, specific information to be disclosed, signed and dated by client and witness and clearly indicate that a copy of the consent was offered to the client prior to contacting any Medical/D&A/MH Treatment Providers, SARPH/PNAP & Other Case Management, Family Members and Significant Others. Outpatient Manager will conduct monthly audit to verify the accurate completion of consents and provide ongoing training of this requirement. This deficiency was already corrected and implemented by Senior Outpatient Manager. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in one of two applicable client records reviewed.
Client #9 was admitted on July 5, 2022 and discharged August 15, 2022. Client #9's record contained a treatment and rehabilitation plan dated July 6, 2022 that indicated individual sessions were to be conducted two times per month, as well as group sessions conducted two times per month. Client #9's record did not contain documentation of at least two individual sessions for the weeks of July 10, 2022 to July 16, 2022, July 17, 2022 to July 23, 2022, and July 25, 2022 to July 30, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Reeducated Therapist of partial hospitalization requirements of providing two individual sessions weekly as well as group sessions two times weekly. Reeducated Therapist on accurate and timely documentation of all services provided as well as accurately reflecting on Record of Service. Office Manager will conduct bi-weekly audits to insure all necessary services are provided and documented. Outpatient Manager will conduct monthly audit to insure all necessary services are being provided and reflected with accurate and timely documentation. Senior Outpatient Manager has already addressed this deficiency and implemented corrective actions. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to ensure that counseling was provided to clients on a regular and scheduled basis, that included individual counseling, at least twice weekly in one of two applicable records reviewed.
Client #10 was admitted to the partial hospitalization level of care on July 25, 2022 and discharged on September 1, 2022. Client #10 ' s treatment and rehabilitation plan dated August 16, 2022, identified individual counseling every significant contact. A review of the record of service and progress notes indicated that Client #10 was scheduled for individual counseling only once a week during the partial hospitalization level of care, rather than at least twice weekly.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Reeducated Therapist of partial hospitalization requirements of providing two individual sessions weekly as well as group sessions two times weekly. Reeducated Therapist on accurate and timely documentation of all services provided as well as accurately reflecting on Record of Service. Reeducated Therapist that Treatment Plans must indicate an accurate description of the services and frequency of said services per level of care. Office Manager will conduct bi-weekly audits to insure all necessary services are provided and documented. Outpatient Manager will conduct monthly audit to insure all necessary services are accurately indicated in Treatment Plan and are being provided and reflected with accurate and timely documentation . Senior Outpatient Manager has already addressed this deficiency and implemented corrective actions. |
709.83(a)(8) LICENSURE Client records
709.83. 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:
(8) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document an accurate record of service in one of two client records reviewed.
Client #9 was admitted July 5, 2022 and discharged August 15, 2022. Client #9's record of service listed an individual session was provided on July 12, 2022. No other individual session was documented on the record of service, however there was documentation of progress notes for individual session date July 6, 2022, July 7, 2022, July 12, 2022, July 19, 2022, August 2, 2022, August 4, 2022, August 10, 2022, August 11, 2022, and August 15, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Reeducated Therapist of partial hospitalization requirements of providing two individual sessions weekly as well as group sessions two times weekly. Reeducated Therapist on accurate and timely documentation of all services provided as well as accurately reflecting on Record of Service. Office Manager will conduct bi-weekly audits to insure all necessary services are provided and documented. Outpatient Manager will conduct monthly audit to insure all necessary services are being provided and reflected with accurate and timely documentation in both progress notes and on Record of Service. Senior Outpatient Manager has already addressed this deficiency and implemented corrective actions. |
709.83(a)(11) LICENSURE Client records
709.83. 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 provide follow-up information in one of two client records reviewed.
Client #9 was admitted on July 5, 2022 and was discharged August 15, 2022. By facility policy, follow-up information is to be obtained six months after discharge. A follow-up should have occurred by February 15, 2023, however there was no documentation of follow up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapist was reeducated on insuring that clients records are completed in a timely manner upon a clients discharge in order for record to be transferred to the Medical Records department, who will then complete six month follow-up with client that will be added to clients closed record. Office Manager will bi-weekly conduct record audits to insure the timely completion of required documents to insure the closure of the record for transfer to Medical Records. Outpatient Manager will conduct monthly audits to insure the timely completion of required documents to insure the closure of the record for transfer to Medical Records and will provide ongoing training and clinical support to therapist. Senior Outpatient Manager has already addressed this deficiency and has implemented POC. |