INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on October 29, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Grace Recovery Services 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of administrative records and staff interview, the facility failed to conduct unannounced fire drills at least once a month. The facility fire drill log showed that no fire drills were conducted in January 2025, February 2025, March 2025, April 2025 and May 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 14, 2025 annual licensing renewal inspection.
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Plan of Correction
The facility will conduct unannounced fire drills at least once per month and document each drill using the standardized digital fire drill log. The Facility Director, or a designated backup when unavailable, will be responsible for completing and documenting the drill. All staff will be re-educated on fire drill requirements and documentation procedures by 11/28/2025, including reviewing expectations during new-hire onboarding. To ensure ongoing compliance, the Facility Director will review the digital fire drill log one week prior to the end of each month to verify that the drill has been completed and properly documented, and will take immediate corrective action if it has not. The facility will also include monthly fire drill completion as part of its internal quality assurance monitoring. Full compliance will be achieved by 11/28/2025. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to ensure there was a complete client record, which includes a discharge summary, in one of three client records.
Client #1 was admitted to the outpatient level of care on October 31, 2024 and was discharged February 28, 2025. No discharge summary was completed for Client #1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that a complete client record, including a discharge summary, is completed for all clients at discharge. The Facility Director will be responsible for confirming that a discharge summary is completed at the time of case closure. All clinical staff will be re-educated on discharge documentation requirements, procedures, and timelines by 11/28/2025, with expectations reviewed during new-hire onboarding. To ensure ongoing compliance, the Facility Director will review discharge documentation monthly using the chart audit spreadsheet to verify completion of required discharge summaries, and will take immediate corrective action if any are found to be missing or incomplete. Monthly discharge documentation monitoring will also be incorporated into internal quality assurance processes. Full compliance will be achieved by 11/28/2025. |