INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on March 16, 2022, 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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705.10 (b) (3) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
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Observations
Based on a physical plant inspection and discussion with facility staff on March 16, 2022, a fire alarm pull station in the kitchen by the lounge was pulled down as if it would activate an alarm, however no alarm was sounding. The facility reported that pull station is not operative with the smoke alarm system being utilized in the facility. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Not in use fire alarms have been labelled as such. Existing not in use fire safety systems will be inspected by a qualified fire protection service on 3/25/22. Non operative components will be labelled and/or removed in accordance with the recommendation of the inspecting office.
Ongoing responsibility of Facility Director.
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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 on March 16, 2022, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The inspection tags on the six fire extinguishers in the facility expired January 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire extinguishers were inspected and serviced on 3/17/22 including updated service tags on each extinguisher. Annual fire extinguisher inspection will be the ongoing responsibility of the Facility Director. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of two personnel records, the facility failed to ensure one employee was instructed in the use of the fire extinguishers upon staff employment. Employee #1 was hired as a counselor on March 7, 2022 and was current in that position. Employee #1 was not instructed in the use of the fire extinguishers until March 17, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility policy and procedures were updated to reflect new hire fire safety and emergency training within 7 days of hire. Ongoing responsibility of Facility Director. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of two personnel records, the facility failed to ensure one employee was trained to perform assigned tasks during emergencies.Employee #1 was hired as a counselor on March 7, 2022 and was current in that position. Employee #1 was not trained to perform assigned tasks during emergencies until March 17, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility policy and procedures were updated to reflect new hire fire safety and emergency training within 7 days of hire. Ongoing responsibility of Facility Director. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the written fire drill record from October 2021 to February 2022, the facility failed to document whether the fire alarm or smoke detector was operative. The log had a column titled " utilize smoke alarm system " and the box indicated yes but did not state whether the smoke alarm system was operative. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the October 13, 2021 inspection.
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Plan of Correction
Fire drill logs templates were updated to include a column which indicates acknowledgement that the fire alarm(s) or smoke detector(s) used during the drill was operative. Ongoing responsibility of Facility Director to ensure fire drills are recorded appropriately through biannual log review. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the written fire drill record from October 2021 to February 2022, the facility failed to prepare alternate exit routes to be used during fire drills. The seven fire drills all listed rear for the exit used. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff conducting emergency evacuation simulations will identify and demonstrate alternate exit routes to utilize during emergency situations. Various evacuation routes are posted for public view throughout the facility and all emergency exits are labelled. Ongoing responsibility of Facility Director to ensure fire drills are recorded appropriately through biannual log review. |
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 seven client records the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one record reviewed.Client #6 was admitted on November 16, 2021 and was still active at the time of the inspection. A consent to release form for a local church was signed and dated February 4, 2022 that failed to include the purpose of the disclosure. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the October 13, 2021 inspection.
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Plan of Correction
Correction has been made to the client record referenced to include all necessary information. Relevant clinical and administrative staff have reviewed confidentiality protocol and how to appropriately complete all sections of client consents. Consent records will continue to be monitored during chart audits. This continues to be the ongoing responsibility of Clinical Supervisor. |
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 seven client records, the facility failed to give two applicable clients the opportunity to request reconsideration of a decision terminating treatment.These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the October 13, 2021 inspection.
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Plan of Correction
Relevant administrative and clinical staff have reviewed discharge protocol to ensure proper documentation is signed upon discharge. Administrative Discharge notices were updated on October 13, 2021 to reflect a reiterated acknowledgement of the grievance and appeals policy and their opportunity to request reconsideration of a decision terminating treatment. "I acknowledge that I have the opportunity to request reconsideration of this decision utilizing the grievance and appeals process identified in my admission documents." Compliance will continue to be monitored during monthly chart audits; ongoing responsibility of clinical supervisor |