INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential 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 review of the facility's fire extinguishers, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. The facility ' s fire extinguishers were last inspected in September of 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
Fire extinguishers were inspected and approved on January 17, 2025 by the company contracted to maintain the fire extinguishers.
Ongoing Compliance:
The Facility Director will maintain a digital calednar tracking system with reminders 30 days before the next fire extinguisher inspection is due.
Training:
Company leadership will be briefed on the inspection schedule and digital calendar tracking process by 02/17/2025.
Oversight:
The Facility Director will check compliance annually.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/17/2025.
Documentation:
Fire extinguisher inspection records will be maintained at the facility.
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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 the facility fire drill log for the months of May 2024 through December 2024, the facility failed to provide documentation of a fire drill being conducted the months of May 2024, June 2024, July 2024, August 2024, September 2024, October 2024, and December 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
Fire drills will continue monthly going forward.
Ongoing Compliance:
The Facility Director will ensure maintenance of a fire drill log by using a digital calendar system to ensure monthly reminders to conduct drills.
Training:
Facility staff will be briefed on fire drill procedures and documentation requirements by 02/15/2025
Oversight:
The Facility Director will maintain and review the fire drill log monthly to ensure documentation is complete and up to date.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/15/2025
Documentation:
Fire drill logs will be maintained and reviewed monthly.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 facility fire drill log for the month of November 2024, the facility failed to maintain a written fire drill record including the amount of time it took for evacuation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
The fire drill log has been updated to include time taken to exit during the fire drill.
Ongoing Compliance:
The Facility Director will track on the fire drill log, the time taken to evacuate during monthly fire drills.
Training:
Company leadership will be briefed on the updated documentation process by 02/17/2025.
Oversight:
The Facility Director will review the fire drill log monthly to ensure all required information, including evacuation times, are documented.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/17/2025.
Documentation:
Updated fire drill logs and spreadsheet tracker will be maintained.
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on applicable client records reviewed, the facility failed to ensure there was documentation of written acknowledgment by the client that the client had been made aware of their rights in two of two records.
Client #1 was admitted on November 25, 2024 and was still active at the time of the inspection.
Client #2 was admitted on October 31, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
The facility will ensure client rights acknowledgement signatures are obtained from existing clients and documented in their respective client records.
Ongoing Compliance:
The Facility Director will ensure that all current client intake packets are checked for the required acknowledgment form by March 01, 2025.
Training:
Staff will be trained by 02/20/2025 to verify, at the beginning of the first session, that the client rights acknowledgment has been signed.
If the form is missing, staff will obtain the client's signature during the first session and document it immediately in the client record.
Oversight:
The Facility Director will conduct monthly audits of new client files to ensure the acknowledgment form is signed and properly documented.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 03/01/2025.
Documentation:
Client rights acknowledgment forms and monthly audit records will be maintained.
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on applicable client records reviewed, the facility failed to ensure there was documentation of intake procedures that included the disclosure of criteria for admission, treatment, completion, and discharge in two of two records.
Client #1 was admitted on November 25, 2024 and was still active at the time of the inspection.
Client #2 was admitted on October 31, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action:
Immediate Action:
The facility will ensure documentation of intake procedures including the disclosure of criteria for admission, treatment, completion, are in client records prior to admission.
Ongoing Compliance:
The Facility Director will ensure that all client intake packets are checked for documentation of the intake procedures, including the disclosure of criteria for admission, treatment, completion, and discharge.
Training:
Staff will be trained by 03/15/2025 to verify, at the beginning of the first session, that the intake procedure documentation has been completed and signed by the client.
If the form is missing, staff will obtain the client's signature during the session and document it immediately in the client record.
Oversight:
The Facility Director will conduct monthly audits of new client files to ensure the intake procedure documentation is completed and properly filed.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 03/15/2025.
Documentation:
Intake procedure documentation and monthly audit records will be maintained.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on applicable client records reviewed, the facility failed to ensure there was documentation of client orientation to the project, which included a familiarization with project policies in two of two records.
Client #1 was admitted on November 25, 2024 and was still active at the time of the inspection.
Client #2 was admitted on October 31, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
The facility will ensure documentation of client orientation to the project, which includes a familiarization with the program through signed client handbooks.
Ongoing Compliance:
The Facility Director will ensure that all client handbooks are checked for documentation of client orientation, including familiarization with project policies.
Training:
Staff will be trained by 02/20/2025 to verify, at the beginning of the first session, that client handbook documentation has been completed and signed by the client.
If the form is missing, staff will obtain the client's signature during the session and document it immediately in the client record.
Oversight:
The Facility Director will conduct monthly audits of new client files to ensure the client orientation documentation is completed and properly filed.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/20/2025.
Documentation:
Client orientation documentation and monthly audit records will be maintained.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on applicable client records reviewed, the facility failed to ensure there was documentation of client orientation to the project, which included a familiarization with hours of operation in two of two records.
Client #1 was admitted on November 25, 2024 and was still active at the time of the inspection.
Client #2 was admitted on October 31, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
The facility will ensure client orientation to the project through client handbooks, which include familiarization with hours of operation.
Ongoing Compliance:
The Facility Director will ensure that all client intake packets are checked for documentation of client orientation, including familiarization with hours of operation.
Training:
Staff will be trained by 02/17/2025 to verify, at the beginning of the first session, that client orientation documentation has been completed and signed by the client.
If the form is missing, staff will obtain the client's signature during the session and document it immediately in the client record.
Oversight:
The Facility Director will conduct monthly audits of new client files to ensure the client orientation documentation is completed and properly filed.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/17/2025.
Documentation:
Client orientation documentation and monthly audit records will be maintained. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on applicable client records reviewed, the facility failed to ensure there was documentation of client orientation to the project, which included a familiarization with the fee schedule in one of two records.
Client #2 was admitted on October 31, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
The facility will ensure familiarization with the fee schedule through the informed consent document.
Ongoing Compliance:
The Facility Director will ensure that all client intake packets are checked for documentation of client orientation, including familiarization with the fee schedule.
Training:
Staff will be trained by 02/17/2025 to verify, at the beginning of the first session, that client orientation documentation has been completed and signed by the client.
If the form is missing, staff will obtain the client's signature during the session and document it immediately in the client record.
Oversight:
The Facility Director will conduct monthly audits of new client files to ensure the client orientation documentation is completed and properly filed.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/17/2025.
Documentation:
Client orientation documentation and monthly audit records will be maintained.
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on applicable client records reviewed, the facility failed to ensure there was documentation of client orientation to the project, which included a familiarization with the services provided in one of two records.
Client #2 was admitted on October 31, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
The facility will ensure familiarization with the services provided through client handbooks.
Ongoing Compliance:
The Facility Director will ensure that all client intake packets are checked for documentation of client orientation, including familiarization with the services provided in the client handbook.
Training:
Staff will be trained by 02/17/2025 to verify, at the beginning of the first session, that client orientation documentation has been completed and signed by the client.
If the form is missing, staff will obtain the client's signature during the session and document it immediately in the client record.
Oversight:
The Facility Director will conduct monthly audits of new client files to ensure the client orientation documentation is completed and properly filed.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/17/2025.
Documentation:
Client orientation documentation and monthly audit records will be maintained.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on applicable client records reviewed, the facility failed to ensure there was documentation of intake procedures that included the consent to treatment in one of two records.
Client #2 was admitted on October 31, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
The facility will ensure documentation of intake procedures and consent to treatment through the informed consent document.
Ongoing Compliance:
The Facility Director will ensure that all client intake packets are checked for documentation of consent to treatment.
Training:
Staff will be trained by 02/17/2025 to verify, at the beginning of the first session, that the informed consent documentation has been completed and signed by the client.
If the form is missing, staff will obtain the client's signature during the session and document it immediately in the client record.
Oversight:
The Facility Director will conduct monthly audits of new client files to ensure the informed consent documentation is completed and properly filed.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/17/2025.
Documentation:
Informed consent documentation and monthly audit records will be maintained.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on applicable client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client in one of two records.
Client #2 was admitted on October 31, 2024 and was still active at the time of the inspection.
The comprehensive treatment and rehabilitation plan developed on November 7, 2024 did not include documentation of the plan being developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
The facility will ensure clients are involved in treatment plan development, and this involvement will be shown with the client's signature on the treatment plan.
Ongoing Compliance:
The Facility Director will ensure that all client treatment plans are reviewed to confirm the client's signature is present, indicating their involvement through monthly audits.
Training:
Staff will be trained by 02/17/2025 to verify, at the time of treatment plan development, that the client's signature is obtained and documented on the treatment plan.
Oversight:
The Facility Director will conduct monthly audits of treatment plans to ensure the client's involvement and signature are properly documented.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/17/2025. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services in one of two records.
Client #1 was admitted on November 25, 2024 and was still active at the time of the inspection.
A comprehensive treatment and rehabilitation plan was developed with the client on December 6, 2025, however, there was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
The facility will ensure that all treatment plans include the type and frequency of treatment services.
Ongoing Compliance:
The Facility Director will review all treatment plans to confirm that the type and frequency of services are included in treatment plans through monthly audits.
Training:
Staff will be trained by 02/17/2025 to verify that treatment plans include the type and frequency of services.
Oversight:
The Facility Director will conduct monthly audits of treatment plans to ensure the type and frequency of services are included and properly documented.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/17/2025.
Documentation:
Treatment plans with the type and frequency of services, and monthly audit records will be maintained.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of applicable client records, the facility failed to document proposed type of support service on individual treatment plans in one of two records.
Client #1 was admitted on November 25, 2024 and was still active at the time of the inspection.
A comprehensive treatment and rehabilitation plan was developed with the client on December 6, 2025, however, there was no documentation of proposed type of support service.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Immediate Action:
The facility will ensure that all treatment plans include the proposed types of support services
Ongoing Compliance:
The Facility Director will review all treatment plans to confirm that the proposed types of support services are documented in the treatment plan.
Training:
Staff will be trained by 02/17/2025 to verify that all treatment plans include the proposed types of support services.
Oversight:
The Facility Director will conduct monthly audits of treatment plans to ensure the proposed types of support services are included and properly documented.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/17/2025.
Documentation:
Treatment plans with proposed types of support services, and monthly audit records will be maintained.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in one of two records.
Client #2 was admitted on October 31, 2024 and was still active at the time of the inspection.
A treatment and rehabilitation plan was developed on November 7, 2024. A treatment and rehabilitation plan update was due no later than January 7, 2025, but was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediate Action:
The facility will ensure all treatment plans have been reviewed and updated every 60 days.
Ongoing Compliance:
The Facility Director will implement a tracking alert system in the EHR to monitor treatment plan review dates and ensure updates occur at least every sixty days.
Training:
Staff will be trained by 02/17/2025 on the requirement to review and update treatment plans every sixty days and how to properly document these updates.
Oversight:
The Facility Director will conduct quarterly audits of treatment plans to verify that updates are made and documented within the required timeframe.
Person(s) Responsible:
Facility Director
Full Compliance Date:
The facility will be in full compliance as of 02/17/2025.
Documentation:
Updated treatment plans and tracking system audit records will be maintained.
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