INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Graniteville House of Recovery 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure all facility heaters were permanently mounted or installed as a space heater was found in counseling office C.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The device was removed and all staff have been retrained on the disallowance of space heaters. Facility Director will confirm the absence of space heaters during physical plant walks at least 1x quarterly. Ongoing responsibility of Facility Director. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
At the time of the inspection, there was a fire extinguisher, located next to the rear exit door, that was last inspected in February 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director will confirm that all fire extinguishers have been included in annual fire extinguisher inspection.
Facility Director will confirm the compliance of fire extinguishers during physical plant walks at least 1x quarterly. Ongoing responsibility of Facility Director.
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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 the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable client record reviewed.
Client #4 was admitted on October 6, 2023 and was involuntarily terminated on November 14, 2023. There was no documentation in the record of the client receiving written notice of the termination.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative discharge protocol has been updated to assure the record reflects that the client receives all necessary notices and information regarding their discharge in writing. Facility director will affirm protocol is maintained during chart audit. All relevant staff have been retrained on updated protocol, and associated documentation. Ongoing responsibility of Facility Director.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to ensure a client was given an opportunity to request reconsideration of a decision terminating treatment in one of one applicable client record reviewed.
Patient #4 was admitted on October 6, 2023 and was involuntarily terminated on November 14, 2023. There was no documentation in the record indicating the client was given an opportunity to request reconsideration of the termination.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Administrative discharge protocol has been updated to assure the record reflects that the client receives all information regarding their right to appeal or request reconsideration in writing. All relevant staff have been retrained on updated protocol and associated documentation. |