INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18-19, 2026, 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on August 19, 2026, the facility failed to ensure the hot water temperature did not exceed 120 degrees F. Resident bathroom B1 had a water temperature of 121 degrees F when tested.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility adjusted the hot water temperature to ensure it does not exceed 120°F. Hot water temperatures will be monitored periodically to ensure continued compliance. Responsibility of Facility Director. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and the facility's policy manual, the facility failed to follow their policy to contact a client's emergency contact within 12 hours, when the client leaves against medical advice in one out of one applicable record reviewed.
Client #4 was admitted on February 10, 2026, and left against medical advice on April 10, 2026. There was no documentation in the record that the emergency contact was notified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director re-educated clinicians on the requirement to notify a client's emergency contact within 12 hours when a client leaves against medical advice and to document the notification in the client record to ensure that future AMA discharges include timely notification and proper documentation in accordance with facility policy. Compliance will be monitored through monthly chart audits. Responsibility of Facility Director. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in four out of seven records reviewed.
Client #1 was admitted on May 6, 2026, and was still active at the time of the inspection. There was documentation that the facility contacted a county probation office on May 6, 2026, and May 29, 2026; however, the informed and voluntary consent for the county probation office was not signed by the client until June 17, 2026.
Client #4 was admitted on February 10, 2026, and was discharged on April 10, 2026. There was documentation that the facility contacted a dental provider on February 11, 2026; however, the informed and voluntary consent for the dental provider was not signed by the client until February 12, 2026.
Client #5 was admitted on March 4, 2026, and was discharged on May 4, 2026. There was documentation that the facility contacted an attorney on March 11, 2026; however, the informed and voluntary consent for the attorney was not signed by the client until March 18, 2026.
Client #7 was admitted on June 17, 2026, and was discharged on July 10, 2026. There was no documentation that the facility contacted a county probation office on June 17, 2026; however, the informed and voluntary consent for the county probation office was not signed by the client until June 18, 2026.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 was admitted on 5/6/26 and original release was signed on 5/6/26. Corrected release was signed on 6/17/26. Facility Director re-educated clinicians on the requirement to obtain an informed and voluntary consent from the client prior to the disclosure of any information contained in the client record to ensure that future disclosures are made only after appropriate consent has been obtained and documented. Compliance will be monitored through monthly chart audits. Responsibility of Facility Director. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one out of seven records reviewed.
Client #1 was admitted on May 6, 2026, and was still active at the time of the inspection. The informed and voluntary consent signed by the client on June 17, 2026, for a county probation office, did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 was admitted on 5/6/26 and original release was signed on 5/6/26. Corrected release was signed on 6/17/26. Facility Director re-educated clinicians on the requirement that all informed and voluntary consents include the specific information to be disclosed prior to any disclosure of client information to ensure that all releases are completed in accordance with confidentiality requirements. Compliance will be monitored through monthly chart audits. Responsibility of Facility Director. |
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 client records, the facility 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 out of seven records reviewed.
Client #1 was admitted on May 6, 2026, and was still active at the time of the inspection. The informed and voluntary consent signed by the client on June 17, 2026, for a county probation office, did not include the purpose of disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 was admitted on 5/6/26 and original release was signed on 5/6/26. Corrected release was signed on 6/17/26. Facility Director re-educated clinicians on the requirement that all informed and voluntary consents include the purpose of disclosure prior to any disclosure of client information to ensure that all releases are completed in accordance with confidentiality requirements. Compliance will be monitored through monthly chart audits. Responsibility of Facility Director. |