INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 12, 2024 through November 13, 2024 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of eleven personnel records, the project failed to ensure that one of three counselor assistants reviewed received direct observation and/or close supervision that is in compliance with the regulatory timeframes.
Employee #11 was hired as a counselor assistant on April 30, 2024 and was a current employee at the time of the inspection. Employee #11 was initially hired with a nonqualifying bachelor ' s degree and therefore was reviewed as having a high school diploma. Employee #11 could only counsel clients under the direct observation of a trained counselor or clinical supervisor for the first three months of employment and only under close supervisor for the following nine months. There was no documentation in the personnel record of direct observation from April 30, 2024 through July 30, 2024 and no documentation of close supervision from July 30, 2024 through until the date of the inspection.
Direct observation is defined by regulation as follows: " In person observation of staff working in a clinical setting for the purpose of planning, oversight, monitoring and evaluating their activities " .
Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " .
These findings were reviewed with project 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
The Director of Clinical Operations will hold a training with clinical supervisors to review regulations for counselor assistants. Assigned clinical supervisors will start direct observation of counselor assistants who need close supervision as defined by 704.9 for one hour per week following this training.
3.) When will they be corrected
Training will begin on 12/16/2024. Direct observation will begin on 12/16/2024.
4.) How will the facility ensure the deficiency does not recur
DCO will regularly review each week's supervision logs from clinical supervisor to ensure that close supervision of counselor assistants is performed.
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records, four months of staff schedules and the Staffing Requirement Facility Summary Report (SRFSR), the project failed to ensure that at least a sufficient number of staff persons trained in CPR and first aid was onsite during the project's hours of operation.
The facility ' s hours of operation are Monday - Friday 8:00am - 8:00 pm and Saturday - Sunday 8:00 am - 5:00pm. There were no staff members with a current CPR/First Aid Certificate between the hours of 4:00 PM and 8:00 PM on Mondays through Fridays, 4:00 PM through 5:00 PM on Saturdays and 8:00 AM through 5:00 PM on Sundays.
These findings were reviewed with project 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
DCO will assign staff member with CPR certification to work 4PM-8PM Monday-Saturday and 8AM-5PM on Sundays. DCO will arrange for more staff to be CPR certified across all departments. Facility will provide training opportunities for staff utilizing the American Heart Association. The goal will be to have at least 6 more staff CPR certificates by 12/31/2024.
3.) When will they be corrected
Starting 12/16/2024 a staff member will be assigned the above schedule. DCO will arrange for additional CPR certification starting 12/31/2024.
4.) How will facility ensure the deficiency does not recur.
DCO will audit staff HR files monthly to ensure a CPR certification is valid for all hours of operation starting 12/31/2024.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of administrative documents, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This finding was reviewed with project 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
DCO will obtain annual financial audit of activities associated with the project's drug/alcohol abuse services to include reference to drug and alcohol treatment activities. DCO will present this to licensing agent for verification of compliance with standards.
3.) When will they be corrected
DCO will correct the annual financial audit by end of year 12/31/2024.
4.) How will facility ensure the deficiency does not recur.
DCO will communicate needed financial audits to administration team to ensure yearly compliance with regulations.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one applicable client record reviewed.
Client #12 was admitted on May 22, 2024 and was involuntarily discharged on September 23, 2024. It was not documented in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment.
These findings were reviewed with project 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
The Director of Clinical Operations will update the program policy to include written notification of the decision to involuntarily terminate the client's treatment. The client will be notified of the reason for the decision to involuntarily terminate. The client will have an opportunity to request reconsideration of a decision terminating treatment. DCO will train all clinical staff on the policy for involuntary termination of treatment.
3.) When will they be corrected
Program policy will be in effect on 12/16/2024. All clinical staff will be trained by 12/31/2024.
4.) How will the facility ensure the deficiency does not recur
DCO will audit case management files monthly to ensure policy is being followed for involuntary termination of clients.
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