INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 28, 2023 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 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from September, 2022 through August, 2023 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on December 23, 2022 and then not again until July 5, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire drills will be performed as scheduled and/or required including sleeping hours fire drills biannually. Ongoing responsibility of Facility Director to ensure fire drills are performed and recorded as required through biannual log review. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in five out of eight applicable records.
Client #2 was admitted on March 14, 2023 and was still active at the time of the inspection.
Client #3 was admitted on March 31, 2023 and was still active at the time of the inspection.
Client #4 was admitted on May 5, 2023 and was still active at the time of the inspection.
Client #8 was admitted on January 12, 2023 and was discharged on May 9, 2023.
Client #9 was admitted on February 16, 2023 and was discharged on May 18, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will train relevant staff to effectively complete the evaluation of biopsychosocial. Clinical Supervisor responsible for monthly record review to ensure improvement and completeness of BSP evaluation. |