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Home My WebLink AboutANNUAL SURVEY GROUP HOME #4 10-12-07.TIFOCT 17 ?.001 North Carolina Department of Health and Human S vic Division of Health Service Regulation BUILDING SERVICES Construction Section 2705 Mail Service Center Raleigh N orth Carolina 27699 -2705 Michael F. Easley, Governor �� hO y y'� William L. Warren, Chief Dempsey Benton, Secretary G1 ' Phone: 919- 855 -3893 Fax: 919 -733 -6592 October 12, 2007 Mr. Bruce Melosh v ``e ti l C p� Catawba Valley Behavioral Healthcare 3050 11th Avenue Dr. SE ) /� re Hickory, NC 28602 RE: MHL - Annual Survey FID #944845 Catawba County Group Home #4 722 Eigth Avenue SW Conover (Catawba County) Dear Mr. Melosh: Thank you for the cooperation and courtesies extended during the recent Division of Health Service Regulation (DHSR) - Construction Section Annual Survey of your facility on October 02, 2007. As a result of this survey, deficiencies were cited which will require an acceptable Plan of Correction. The deficiencies cited are listed on the enclosed State Form. Your Plan of Correction should indicate specific action to be taken to correct and prevent recurrence of the deficiency, together with an estimated date of completion. Please note the following governing regulations: 1. Corrective action must begin immediately and be completed within a reasonable time. 2. Any completion date greater than 30 days from date of letter requires written justification from the Provider. Please type or print clearly your corrective action on the enclosed Statement of Deficiencies. SIGN, DATE AND RETURN the Plan of Correction to DHSR -Construction Section by 11/12/2007. Failure to return this signed Plan of Correction within this time period could jeopardize the status of your license. This office will schedule a follow -up inspection after the last completion date indicated on the signed Plan of Correction. Prior to making any changes to your facility you will need to verify with the local Building Official whether or not a permit is needed to make the changes on the enclosed Statement of Deficiencies. Please do not hesitate to call us if you have questions or if we can be of further assistance. Sincerely, Garrick Starck Facility Engineering Specialist DHSR - Construction Section Enclosure cc: Mental Health Licensure and Certification Section -with attachment County Building Inspection Department -with attachment John Waters, Exec Dir., Catawba Valley Behavioral Healthcare ?9"Location: 701 Barbour Drive. Dorothea Dix Hospital Campus . Raleigh, N.C. 27603 An Equal Opportunity / Affirmative Action Employer PRINTED: 10/11/2007 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 01 M H LO18026 B. WING 10/02/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CATAWBA COUNTY GROUP HOME #4 722 EIGHTH AVENUE S.W. CONOVER, NC 28613 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS - REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) W 000 Initial Comments W 000 An annual survey was conducted by Garrick Starck and Gordon Washburn on October 02, 2007. Information from the Master Facility File indicates that this facility was first licensed on April 08, 1993. Based on this information, we are requiring the facility to meet the1992 Rules for Mental Health, Developmental Disabilities, and Substance Abuse Facilities and Services, and the applicable portions of the 1993 N.C. State Building Code - Volume VII - Residential. W 120 AC -20 Ground Fault Protection W 120 10- 14V.0301. COMPLIANCE WITH BUILDING CODES (b) Each facility operating under a current license issued by DHSR upon the effective date of this Rule shall be in Compliance with all applicable portions of the North Carolina State Building Code in effect at the time the facility was constructed or last renovated. Ground -fault Circuit Interrupter Protection - Per NEC - Section 210 -8 requires GFCI outlets in bathrooms, Garages, Outdoors, Crawlspaces, Unfinished basements, Kitchen countertops and at wet bar sinks. Note: (We are applying this only to existing outlets, not requiring the addition of outlets if not provided). This Rule is not met as evidenced by: " The GFCI receptacle at the rear porch does not trip when tested. Have a licensed electrician Division of Health Service Regulation TITLE (x6) DATE LABORATORY DIRECTOR'S OR PROVIDERISUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM 6899 6T4D21 If continuation sheet 1 of 2 PRINTED: 10/11/2007 FORM APPROVED Division of Health Service Regulation STATE FORM 6898 6T4D21 If continuation sheet 2 of 2 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 01 MHLO18026 B. WING 10102/2007 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 722 EIGHTH AVENUE S.W. CATAWBA COUNTY GROUP HOME #4 CONOVER, NC 28613 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS - REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) W 120 Continued From page 1 W 120 replace the receptacle to provide GFCI protection. V 750 .0304(b)(3) Maintenance of Elec., Mech., & V 750 Water Systems 10A NCAC 27G.0304. FACILITY DESIGN AND EQUIPMENT (b) Safety: Each facility shall be designed, constructed and equipped in a manner that ensures the physical safety of clients, staff and visitors. (3) Electrical, mechanical and water systems shall be maintained in operating condition. This Rule is not met as evidenced by: * Receptacle face plate missing from the washing machine receptacle. Replace face plate. I i I Division of Health Service Regulation STATE FORM 6898 6T4D21 If continuation sheet 2 of 2