INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 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 - Robinson Township 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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709.25 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.
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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, facility records, and staff interview, the facility failed to file a written unusual incident report with the Department within 3 business days following a death due to unusual circumstances.
Client #7 was admitted to the outpatient level of care on August 30, 2023 and was discharged November 28, 2023. Client #7 ' s record indicated that the client ' s family reported to the facility on November 28, 2023 that Client #7 passed away the previous day.
The facility was required to submit a written unusual incident report to the Department no later than December 1, 2023. The facility filed a written unusual incident report for the event on December 6, 2023.
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 Director to ensure that all Clinical Supervisors (Managers) are trained on the unusual incident policy and timeline no later than 4/18/2024.
It is the responsibility of the Manager to ensure that all incidents are reported within the timeline stated in regulations and policy.
To ensure the regulations/policy is followed, the Director will check all DDAP submitted unusual incidents to ensure it is within the required timeline. |