INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21 and March 26 , 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 - Wexford 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.
Upon notification of future DDAP licensing inspections, the Project Director will request a copy of the most recent financial audit so it will be available for review during the inspection.
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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 record.
Client #2 was admitted to the outpatient level of care on October 16, 2023 and was discharged November 15, 2023. The discharge summary in the client record indicated that the client was discharged due to non-compliance. There was no documentation that the facility notified the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Primary Therapist shall ensure the completion of a discharge letter for any patient who is involuntarily discharged from the program.
The Clinical Supervisor shall check this standard is met by randomly reviewing at least 20% of the discharged charts.
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