INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on March 4, 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 - Waynesburg 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 two applicable records.
Client #5 was admitted to the inpatient level of care on October 21, 2024 and was discharged January 3, 2025.
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)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure there is a complete client record which includes follow-up information in two of two applicable records.
Facility policy and procedure states that follow-up information is to be acquired 30 days post discharge.
Client # 5 was admitted to the inpatient level of care on October 21, 2024 and was discharged January 3, 2025. Follow-up information was due no later than February 3, 2025. The client record did not contain any follow-up information at the time of review.
Client #7 was admitted to the inpatient level of care on October 31, 2024 and was discharged January 6, 2025. Follow-up information was due no later than February 6, 2025. The client record did not contain any follow-up information at the time of review.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 25, 2024 annual licensing inspection.
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Plan of Correction
709.53 (a) (11) Follow up information: Consent for staff follow up and Post Discharge follow up have been built into our new electronic health record. A task alert for follow up to assure that all patients are contacted 30 days post discharge was built into the system to allow for ease of follow up. This alert was initially not triggering a follow up task but has recently been corrected. The alert will indicate which patient is to be contacted, method of contact, consent for follow up and the staff member who is required to complete. As of completion of this POC, alert is active and tasking correctly. The clinical manager will review all discharges to assure that the post discharge follow up workflow is intact and will trigger an alert and follow up call is completed successfully. The clinical manager will conduct weekly chart audits for one month and monthly thereafter for the next 6 months to ensure compliance. |