INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 22, 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 - North Strabane 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 fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one record reviewed.
Client #9 was admitted on January 9, 2023 and was current at the time of the inspection. There was no documentation of an informed and voluntary consent from the client for the disclosure of information for a funding source. The facility confirmed that client identifying information was being disclosed to the funder.
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 for a funding agency is completed prior to contacting the funding agency for any pre-certification for authorization. Therapist/Office Manager were reeducated to complete a new informed and voluntary consent from the client for a funding agency, should the funding agency change during the clients treatment. Office Manager will review all informed consents to verify the completion of informed and voluntary consent from the client for a funding agency prior to pre-certification. Outpatient Manager will conduct monthly audits to verify of accurate and complete informed and voluntary consent from the client for a funding agency. 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 fourteen client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information that included the purpose of disclosure in one record reviewed.
Client #9 was admitted on January 9, 2023 and was current at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information for a case manager was signed by the client on January 4, 2023, that did not include the purpose of disclosure.
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 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. This deficiency was already corrected and implemented by Senior Outpatient Manager. |
709.83(a)(4) 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:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to complete case consultation notes upon admission, as is their policy, in two of four applicable client records reviewed.
Client #1 was admitted February 6, 2023 and was active at the time of inspection. No admission case consultation was documented in client #1 ' s record.
Client #2 was admitted January 27, 2023 and was active at the time of inspection. No admission case consultation was documented in client #2 ' s record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapists were reeducated on the necessary paperwork guidelines and the need to complete Case Consultation with Outpatient Manager upon clients admission date per policy. Office Manager will audit to ensure Case Consultation was completed with Outpatient Manager upon clients admission when building clients record. Outpatient Manager will conduct monthly audits to ensure Case Consultations are being completed upon admission per policy.This deficiency was already corrected and implemented by Senior Outpatient Manager. |
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 provide an accurate record of service in four of seven client records reviewed.
Client #1 was admitted February 6, 2023 and was active at the time of inspection. Client #1 ' s record contained a progress note for an individual session on the dates of February 13, 2023 and February 20, 2023. These sessions were not documented on client #1 ' s record of service.
Client #3 was admitted February 6, 2023 and was active at the time of inspection. Client #3 ' s record contained a progress note for a group session on February 13, 2023. This session was not documented on Client #3 ' s record of service.
Client #4 was admitted January 12, 2023 and was active at the time of inspection. Client #4 ' s record contained a progress note for an individual session on February 20. 2023. This session was not documented on Client #4 ' s record of service.
Client #6 was admitted December 5, 2022 and was discharged January 5, 2023. Client #6 ' s record contained a progress note for an individual session on December 29, 2022. This session was not documented on Client #6 ' s record of service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapists were reeducated of the necessity of accurately completing the Record of Service. Therapists were reeducated on insuring that all services provided during treatment are accurately reflected on the Record of Service. Office Managers will conduct bi-weekly audits to insure that all services provided are accurately reflected on the Record of Service. Outpatient Manager will conduct monthly audits to insure that all services provided are accurately reflected on the Record of Service. This deficiency was already corrected and implemented by Senior Outpatient Manager. |