INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21, 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 - 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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709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one of fourteen client records reviewed.
Client #4 was admitted to the partial hospitalization level of care on January 24, 2023 and was current at the time of the inspection. Client #4 ' s record had documentation of referral information that was provided to an outside medical service, however there was not an informed and voluntary consent from the client for the disclosure of information in the record.
These findings were reviewed with 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) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the dated signature of the client in two out of fourteen client records reviewed.
Client #2 was admitted to the partial hospitalization level of care on September 26, 2022 and discharged October 11, 2022. Client #2 had an informed and voluntary consent from the client for the disclosure of information for a spouse, a funder and a physician that was signed by the client but didn ' t include the date.
Client #8 was admitted to the outpatient level of care on August 10, 2022 and discharged on September 22, 2022. Client #8 had an informed and voluntary consent from the client for the disclosure of information for a spouse, a funder and a physician that was signed by the client but didn ' t include the date.
These findings were reviewed with 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) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the date, event or condition upon which the consent will expire in one of fourteen client records.
Client #6 was admitted to the partial hospitalization level of care on February 20, 2022 and was still current at the time of the inspection. Client #6 had informed and voluntary consents for two funding agencies that were signed by the client on February 15, 2023, that did not include the date, event or condition upon which the consents will expire.
These findings were reviewed with 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, the date, event or condition upon which the consent will expire 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. |
709.33 (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 two applicable clients, in writing, of a decision to involuntarily terminate their treatment at the project.
Client #1 was admitted to the partial hospitalization level of care on September 12, 2022 and was discharged on November 22, 2022. There was no documentation of the client being notified in writing of a decision to involuntarily terminate their treatment at the project.
Client # 10 was admitted to the partial hospitalization level of care on October 25, 2022 and was discharged on December 8, 2022. There was no documentation of the client being notified in writing of a decision to involuntarily terminate their treatment at the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapist was reeducated on insuring that documentation of the client being notified in writing of a decision to involuntarily terminate their treatment must be included in the clients record following the involuntary discharge. Office Manager will conduct record audits upon discharge of clients to insure the timely completion of required documentation including involuntary discharge notification was sent to the client. Outpatient Manager will conduct monthly audits to insure the timely completion of required documentation and will provide ongoing training and clinical support to therapist. Senior Outpatient Manager has already addressed this deficiency and has implemented POC. |