INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19, 2022 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(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of twelve personnel records, the facility failed to ensure that one counselor assistant was given a semiannual performance evaluation.
Employee #10 was hired as a counselor assistant on July 22, 2021 and was still in the position at the time of the inspection. Employee #10 received an evaluation on October 15, 2021 and on October 12, 2022; however, did not receive a semiannual review throughout the year.
The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
1.Who will correct the deficiency (job title, not name)
Chief Clinical Officer
2.How the deficiency will be corrected (staff meeting, training, etc.)
Chief Clinical Officer reviewed 7049(b) with the Director of Clinical Operations and clarified that all counselor assistants need to have a semiannual review down.
3.When they will be corrected (corrective action date)
Director of Clinical Operations has placed the semiannual due date for the counselor assistants in his staff review spreadsheet.
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Chief Clinical Officer will make sure to also keep track of due dates of reviews by keeping a spreadsheet. |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 40 clock hours of annual training required for counselor assistants in Employee #10's employee record.
Employee #10 was hired as a counselor assistant on July 22, 2021 and was still in the position at the time of the inspection. The employee's training year was reviewed was from July 22, 2021 through July 21, 2022. Employee #10's employee record only documented five hours of annual training for the training year reviewed.
The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
1.Who will correct the deficiency (job title, not name)
Chief Clinical Officer
2.How the deficiency will be corrected (staff meeting, training, etc.)
Chief Clinica Officer will assign the Counselor Assistant 40 hours' worth of training that needs to be completed in the LMS Relias and make sure that the staff is completing trainings.
3.When they will be corrected (corrective action date)
Chief Clinical Officer will assign the trainings and let the counselor assistant know they have to complete all required hours to stay employed with the company.
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Chief Clinical Officer will run reports in the LMS to check status of completion of the trainings. |
705.25 (5) LICENSURE Food service.
705.25. Food service.
A nonresidential facility may provide meals to clients through onsite food preparation areas, a central food preparation area or contractual arrangements with vendors or caterers. A nonresidential facility which operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to monitor the refrigerator and freezer temperatures according to the regulation. There were no thermometers in the appliance to record temperatures at the time of the inspection.
The 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)
Chief Clinical Officer
2.How the deficiency will be corrected (staff meeting, training, etc.)
All fridges at the physical plant now have a thermometer in them to record temperatures as applicable.
3.When they will be corrected (corrective action date)
11/18/2022
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Chief Clinical Officer and/or designee will do monthly inspections to make sure the thermometers are working and in the fridge. |
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 an administrative review, 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.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1.Who will correct the deficiency (job title, not name)
CEO
2.How the deficiency will be corrected (staff meeting, training, etc.)
CEO is working with his accountant on completing an annual financial audit.
3.When they will be corrected (corrective action date)
CEO reached out to accountant on 10/19/2022 to begin the process.
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Chief Clinical Officer will follow up with the CEO in regard to progress and make sure we have proper documentation for further inspections. |
709.93(a)(11) LICENSURE Client records
709.93. 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 client records, the facility failed to complete a follow up in three out of four applicable records reviewed.
Client #2 was admitted on March 13, 2022 and was discharged on April 14, 2022. The client record did not contain documentation of a follow up.
Client #3 was admitted on May 17, 2022 and was discharged on June 28, 2022. The client record did not contain documentation of a follow up.
Client #4 was admitted on July 11, 2022 and was discharged on September 26, 2022. The client record did not contain documentation of a follow up.
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
1.Who will correct the deficiency (job title, not name)
Chief Clinical Officer
2.How the deficiency will be corrected (staff meeting, training, etc.)
Case Managers and/or designees have been trained on doing follow up calls on clients after discharge. Staff will complete follow up calls and document in the chart under follow up note (7 day, 30, 60, 90)
3.When they will be corrected (corrective action date)
Staff have been trained and will start doing the follow up calls as applicable.
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Chief Clinical Officer will do random chart audits to make sure staff are completing the follow up calls. |