INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25-26, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Nice Homes LLC d/b/a Water Gap Wellness Center 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 fire drill logs from November 2022 -October 2023 , the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the month of July 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1.) Who will correct the deficiency (job title, not name)
Director of Clinical Operations
2.) How the deficiency will be corrected (staff meeting, training, etc.)
The Director of Clinical Operations will be meeting with facilities staff to train on regulations for fire drill safety and monitor fire drills monthly to ensure they are completed.
3.) When will they be corrected (corrective action date)
Starting with October fire drills, they will be monitored monthly as of 10/27/2023.
4.) How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Director of Clinical Operations will sign off on every fire drill monthly as it is presented by designee. Retraining will occur for every new designee for conducting fire drills. The training will be completed by Facilities Manager. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from November 2022 - October 2023, the facility failed to prepare alternative exit route to be used during fire drills, the fire drill logs all noted "second floor" as the exit route.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1.) Who will correct the deficiency (job title, not name)
Director of Clinical Operations
2.) How the deficiency will be corrected (staff meeting, training, etc.)
The Director of Clinical Operations will be meeting with facilities staff to train on regulations for fire drill safety and monitor fire drills monthly to ensure they are accurate with designated exit routes alternating between each month.
3.) When will they be corrected (corrective action date)
Starting with October fire drills, they will be monitored monthly as of 10/27/2023.
4.) How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Director of Clinical Operations will sign off on every fire drill monthly as it is presented by designee and ensure that proper exit routes are being used. Retraining will occur for every new designee for conducting fire drills. The training will be completed by Facilities Manager.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent, in two of fourteen client records. The consent must be in writing and include, but not be limited to the date, event, or condition upon which the consent will expire.
Client #1 admitted on July 1, 2023, and was still an active client at the time of the inspection. A consent to release form dated October 23, 2023, for a family member did not include documentation of an expiration date or condition.
Client #12 was admitted on April 4, 2023, and was discharged on July 1, 2023. A consent to release form dated June 3, 2023, for a family member did not include documentation of an expiration date or condition.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.) Who will correct the deficiency
Director of Clinical Operations
2.) How the deficiency will be corrected
Director of Clinical Operations will hold a consents training by 12/31/2023. All clinical staff will be required to attend. They will be trained on the proper procedures to complete a client consent. Client 1's chart will be corrected by completion of a new accurate consent and rejection of the incomplete consent. Director of Clinical Operations or designee will have new consent be completed with the client.
3.) When will they be corrected
Training will begin in December 2023 with a correction date of 12/31/2023 and will be ongoing throughout 2024. Client 1's chart will be corrected 12/04/2023.
4.) How will facility ensure the deficiency does not recur.
Director of Clinical Operations will conduct a randomized chart review of client consents to ensure accuracy starting 12/11/2023. |