INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11-12, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. 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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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on the review of the facility's policy and procedures manual, the facility failed to develop time frames for their comprehensive staff development program.
The findings were 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)
Director of Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Program Operations will update the policy and procedures manual to include time frames for the comprehensive staff development program. Training Year January to December
Assessment of Training Needs, Overall Training Plan, and Annual Evaluation of Overall Training will be completed by the end of November
3.When they will be corrected (corrective action date)
1/13/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Yearly reviews of the policy and procedure manual.
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop a staff development program that included collecting feedback on completed trainings.
The 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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Program Operations will update the policy and procedures manual to include the ways we are collecting feedback about the trainings.
Staff are completing survey's after the training and also yearly employee survey on trainings that think would be beneficial.
3.When they will be corrected (corrective action date)
1/13/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Yearly reviews of the policy and procedure manual. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a comprehensive staff development program with includes an annual evaluation of the overall training plan.
The 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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Program Operations will update the policy and procedures manual to include time frames for the comprehensive staff development program. Training Year January to December
Assessment of Training Needs, Overall Training Plan, and Annual Evaluation of Overall Training will be completed by the end of November
3.When they will be corrected (corrective action date)
1/13/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Yearly reviews of the policy and procedure manual. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical site inspection, the facility failed to ensure fire extinguishers are inspected and approved annually. Fire extinguisher #157 was last inspected in November 2019.
The 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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Program Operations and/or designee will completely monthly checks of the fire extinguisher to make sure they are in compliance with regulations.
Fire Extinguisher #157 was replaced on the day of the survey with a new fire extinguisher and is now in compliance.
3.When they will be corrected (corrective action date)
1/12/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly environment of care audits |
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 March 2020 through January 2021, the facility failed to conduct unannounced fire drills at least once a month from March through October 2020.
The 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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Program Operations and/or designee will completely monthly fire drills.
Director of Program Operations realized prior to inspection that fire drills need to be done monthly and started to conduct monthly fire drills in November 2020 and forward.
3.When they will be corrected (corrective action date)
1/12/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Quarterly documentation review
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709.22 (b) (2) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(2) Identifying the project ' s purpose and philosophy directly related to drug and alcohol services.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to identify the project's purpose and philosophy related to drug and alcohol services.
The 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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Program Operations updated the policy and procedure manual to include the facility's purpose and philosophy.
The purpose of this program is to provide adequate treatment to individuals who suffer from mental health and substance use issues.
Philosophy
We create a culture of healing, safety and respect. Where all clients are provided the tools they need to live a happy an successful life in recovery from mental health and substance use.
3.When they will be corrected (corrective action date)
1/12/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Yearly policy and procedure audits
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document a completed informed and voluntary consent to release information form that included a name of person, agency, or organization to whom disclosure is made in four out of fourteen records reviewed.
Client #2 was admitted on November 30, 2020 and was still active at the time of the inspection. A consent form dated November 30, 2020 listed the "to:" section as "n/a".
Client #4 was admitted on November 3, 2020 and discharged on December 9, 2020. A consent form dated November 3, 2020 listed the "to:" section as "n/a".
Client #11 was admitted on December 4, 2020 and discharged on January 5, 2021. A consent form dated December 4, 2020 listed the "to:" section as "n/a".
Client #12 was admitted on November 9, 2020 and discharged on December 9, 2020. A consent form dated November 9, 2020 listed the "to:" section as "n/a".
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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Program Operations had a training with all staff that complete consents. Staff were trained an shown examples of how to properly fill out the consents.
Consents that were invalid were redone for all active clients.
3.When they will be corrected (corrective action date)
1/15/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in one out of fourteen records reviewed.
Client #9 was admitted on August 18, 2020 and discharged on December 8, 2020. A consent form dated August 18, 2020 to a funding source permitted release of treatment goals recommendations, participation and attitude towards treatment and financial information.
The findings were 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)
Director of Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Program Operations had a training with all staff that complete consents. Staff were trained an shown examples of how to properly fill out the consents.
Consents that were invalid were redone for all active clients.
3.When they will be corrected (corrective action date)
1/15/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document a completed informed and voluntary consent to release information form that included purpose of disclosure in three out of fourteen records reviewed.
Client #1 was admitted on November 19, 2020 and was still active at the time of the inspection. A consent form dated November 23, 2020 was to a family member.
Client #7 was admitted on December 10, 2020 and discharged on December 23, 2020. A consent form dated December 10, 2020 was to a family member.
Client #12 was admitted on November 9, 2020 and discharged on December 9, 2020. A consent form dated November 14, 2020 had purpose listed as "Other: n/a".
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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Program Operations had a training with all staff that complete consents. Staff were trained an shown examples of how to properly fill out the consents.
Consents that were invalid were redone for all active clients.
3.When they will be corrected (corrective action date)
1/15/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit |
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 a review of client records, the facility failed to document a completed informed and voluntary consent to release information form that included an expiration date, event or condition in one out of fourteen records reviewed.
Client #11 was admitted on December 4, 2020 and discharged on January 5, 2021. A consent form dated December 15, 2020 was to a referral source.
The 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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Program Operations had a training with all staff that complete consents. Staff were trained an shown examples of how to properly fill out the consents.
Consents that were invalid were redone for all active clients.
3.When they will be corrected (corrective action date)
1/15/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document if a copy of the informed and voluntary consent to release information form was offered to the client in eight out of fourteen records reviewed.
Client #2 was admitted on November 30, 2020 and was still active at the time of the inspection. Six consent forms dated November 30, 2020 were to a pharmacy, two hospitals, two family members and a funding source.
Client #4 was admitted on November 3, 2020 and discharged on December 9, 2020. Four consent forms dated November 3, 2020 were to a family member, two hospitals and an unlisted person/organization, as the "to:" section of the form was marked "n/a". A fifth consent form was dated November 27, 2020 to another treatment facility.
Client #5 was admitted on October 30, 2020 and discharged on November 24, 2020. Three consent forms dated November 5, 2020 were to family members. Three additional consent forms dated October 30, 2020 were to two family members and a lawyer.
Client #9 was admitted on August 18, 2020 and discharged on December 8, 2020. Three consent forms dated August 18, 2020 were to a hospital, family member and a funding source. A consent dated November 6, 2020 was to a family member. A fifth consent form dated October 16, 2020 was to probation.
Client #10 was admitted on October 22, 2020 and discharged on December 3, 2020. A consent form dated October 23, 2020 was to a family member.
Client #11 was admitted on December 4, 2020 and discharged on January 5, 2021. Five consent forms dated December 4, 2020 were to a pharmacy, two hospitals, family member and a funding source. A sixth consent form dated December 15, 2020 was to a referral source.
Client #12 was admitted on November 9, 2020 and discharged on December 9, 2020. Four consent to release information forms dated November 9, 2020 were to a pharmacy, hospital, family member and a funding source. A fifth consent form dated November 10, 2020 was to a hospital.
Client #13 was admitted on October 13, 2020 and discharged on December 11, 2020. Two consent forms dated October 13, 2020 were to a hospital and family member.
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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Program Operations had a training with all staff that complete consents. Staff were trained an shown examples of how to properly fill out the consents.
Consents that were invalid were redone for all active clients.
3.When they will be corrected (corrective action date)
1/15/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of the facility's policy, the facility failed to include documentation of all of the required client rights, including that the client shall retain civil rights and liberties except as provided by statute and no client may be deprived of a civil right solely by reason of treatment. In addition, there was no documentation in 14 out of 14 client records reviewed that the clients were made aware of these rights, as it is not included in the client handbook.
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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Client Rights form was updated in the EMR system, the client handbook, and the client right forms that are hanging through out the facility to include the two missing rights.
All active clients signed new a new client rights and responsible form with the two missing client rights.
3.When they will be corrected (corrective action date)
1/15/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly chart audit
Yearly documentation audit |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's policy, the facility failed to include documentation of all of the required client rights, including that the client may not be discriminated against based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. In addition, there was no documentation in 14 out of 14 client records reviewed that the clients were made aware of these rights, as it is not included in the client handbook.
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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Client Rights form was updated in the EMR system, the client handbook, and the client right forms that are hanging through out the facility to include the two missing rights.
All active clients signed new a new client rights and responsible form with the two missing client rights.
3.When they will be corrected (corrective action date)
1/15/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly chart audit
Yearly documentation audit |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of partial hospitalization client records, the facility failed to document type and frequency on client's individual treatment plan in five out of seven records reviewed.
Client #2 was admitted on November 30, 2020 and was still active at the time of the inspection. The December 2, 2020 treatment plan update was missing the required information.
Client #3 was admitted on December 10, 2020 and was still active at the time of the inspection. The December 14, 2020 treatment plan was missing the required information.
Client #5 was admitted on October 30, 2020 and discharged on November 24, 2020. An October 31, 2020 treatment plan was missing the required information.
Client #6 was admitted on July 6, 2020 and discharged on July 20, 2020. A July 8, 2020 treatment plan was missing the required information.
Client #7 was admitted on December 10, 2020 and discharged on December 23, 2020. A treatment plan dated December 12, 2020 was missing the required information.
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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Staff was trained on how to include the type and frequency after the plan section in the treatment plans.
3.When they will be corrected (corrective action date)
1/15/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly chart audit
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of outpatient client records, the facility failed to document type and/or frequency on client's individual treatment plan in five out of seven records reviewed.
Client #9 was admitted on August 18, 2020 and discharged on December 8, 2020. A treatment plan dated August 21, 2020 did not list a type of counseling.
Client #10 was admitted on October 22, 2020 and discharged on December 3, 2020. A treatment plan dated October 27, 2020 did not list type and frequency.
Client #11 was admitted on December 4, 2020 and discharged on January 5, 2021. A treatment plan dated December 4, 2020 did not list type and frequency.
Client #13 was admitted on October 13, 2020 and discharged on December 11, 2020. A treatment plan dated November 2, 2020 did not list type and frequency.
Client #14 was admitted on July 14, 2020 and discharged on August 14, 2020. A treatment plan dated July 15, 2020 did not list type and frequency.
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 Program Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Staff was trained on how to include the type and frequency after the plan section in the treatment plans.
3.When they will be corrected (corrective action date)
1/15/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly chart audit
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