INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 13-14, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on physical plant inspection on November 14, 2025, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. During the licensing inspection it was observed that the blinds in group room " G " were broken in sections allowing counseling sessions to be seen. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Who will correct the deficiency (job title, not name)
- Facilities Director
How the deficiency will be corrected (staff meeting, training, etc.)
- Facilities Director will replace blinds in Room G to ensure adequate privacy so that no counseling session can be seen.
When will they be corrected (corrective action date)
- 11/30/2025
How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations and Quality Assurance Assistant will perform monthly environment of care audits to ensure no damage to blinds in group rooms or counseling rooms. If there is damage, a ticket will be created by e-mail to Facilities Director.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on November 14, 2025, the facility failed to provide a ventilated toilet and washrooms by exhaust fan or window. The bathroom labeled #101 did not have an operational exhaust fan.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Facilities Director
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Facilities Director will replace exhaust fan in bathroom 101.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform monthly environment of care audits to ensure all bathroom fans are operational. If found to be not operational, a ticket will be created by e-mail to Facilities Director.
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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of fire extinguishers upon staff employment in one out of eleven records reviewed. Employee #7 was hired as a counselor on April 15, 2025 and is still current in that position. Employee #7 was to be instructed in the use of a fire extinguisher upon employment but was not trained until May 5, 2025.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Director of Clinical Operations
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Director of Clinical Operations will run audits on all new employees to ensure fire safety training is being completed at hire.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform audits on all new employees to ensure fire safety training is being completed at hire. DCO will utilize Relias to assist with tracking of due dates for fire safety training.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one out of eleven records reviewed.Employee #7 was hired as counselor on April 15, 2025 and is still current in that position. Employee #7 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training did not occur until May 5, 2025. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Director of Clinical Operations
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Director of Clinical Operations will run audits on all new employees to ensure emergency procedures training is being completed at hire.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform audits on all new employees to ensure emergency procedures training is being completed at hire. DCO will utilize Relias to assist with tracking of due dates for emergency procedures training.
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709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in two out of five applicable records reviewed. The facility's policy and procedures manual states that one case consultations must be completed with every episode.Client # 2 was admitted to the partial hospitalization program on July 5, 2025 and was discharged on August 23, 2025. The record did not contain a case consultation.Client # 3 was admitted to the partial hospitalization program on April 3, 2025 and was discharged on April 10, 2025. The record did not contain a case consultation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Director of Clinical Operations
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Director of Clinical Operations will run weekly audits for case consultations.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform audits on all clinical charts to ensure case consultations are being completed in a timely manner. Clinical staff will be trained in a meeting regarding case consultation due dates.
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709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
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Observations
Based on a review of partial hospitalization client records and the facility policy manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, within 7 days, 30 days, 60 days, 6 months and one year, per facility policy in two of four applicable records reviewed. Client # 2 was admitted to the partial hospitalization program on July 5, 2025 and was discharged on August 23, 2025. The record did not contain documentation of follow-up information. Client # 4 was admitted to the partial hospitalization program on August 27, 2025 and was discharged on September 17, 2025. The record did not contain documentation of follow-up information. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Director of Clinical Operations
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Director of Clinical Operations or Quality Assurance Assistant will run monthly audits for follow up notes.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform audits on all clinical charts to ensure follow up notes are being completed in a timely manner. Director of Family and Alumni Program will be trained on completing follow up notes in a timely manner.
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