INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 26-27, 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 dba Water Gap Wellness 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:
|
Plan of Correction
|
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection, the facility failed to not permit in the facility heaters that are not permanently mounted or installed. A portable space heater was observed in room #9.
This finding was reviewed with the facility staff during the licensing process.
|
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 space heaters. All staff at orientation will be trained on not having space heaters as they are within the regulations and pose a safety hazard.
3.) When will they be corrected (corrective action date)
Starting on 12/26/2023, staff will be trained on portable space heaters.
4.) How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Director of Clinical Operations or designee will conduct a physical site inspection to ensure no space heaters are found. Staff will be trained regularly on the safety hazards of portable space heaters. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
|
Observations
Based on a physical site inspection, it was determined that the facility failed to ensure fire extinguishers were mounted to the wall.
The fire extinguisher located in room #8 was not secured to a wall.
This finding was reviewed with the facility staff during the licensing inspection.
|
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 extinguishers. The fire extinguisher located in room 8 was removed promptly. Physical site inspections of the facility will be held monthly to ensure compliance with the regulation.
3.) When will they be corrected (corrective action date)
Starting on 12/26/2023, staff will be trained on fire extinguishers and physical site inspections will be held regularly by DCO or designee.
4.) How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Director of Clinical Operations or designee will conduct a physical site inspection to ensure fire extinguishers are within regulation. Facility staff will be trained on regulation with fire extinguishers. |
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.
|
Observations
Based on a physical site inspection, it was determined that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company
The fire extinguisher located in room #8 was last inspected in June 2021.
This finding was reviewed with the facility staff during the licensing inspection.
|
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 extinguishers and ensuring that they are inspected and approved annually by fire extinguisher company. The fire extinguisher located in room 8 was removed promptly. Physical site inspections of the facility will be held monthly to ensure compliance with the regulation on inspections.
3.) When will they be corrected (corrective action date)
Starting on 12/26/2023, staff will be trained on fire extinguisher inspection dates and physical site inspections will be held regularly by DCO or designee.
4.) How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Director of Clinical Operations or designee will conduct a physical site inspection to ensure fire extinguishers are inspected annually by local fire extinguisher company. Facility staff will be trained on regulation with fire extinguishers. |
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.
|
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.
|
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 drills and ensuring that they are conducted regularly once per month. DCO will sign off on every fire drill per month.
3.) When will they be corrected (corrective action date)
Starting on 12/26/2023, fire drills will be inspected and signed off from DCO. Training will be conducted to ensure all fire drills are conducted promptly each month.
4.) How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Director of Clinical Operations or designee will review each fire drill documentation per month. Training will be conducted regularly on conducting fire drills.
|
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
|
Observations
Based on a review of fire drill logs from November 2022 - October 2023, the facility failed to conduct fire drills during normal staffing conditions. All documented fire drills for the review period were conducted between 10:10-10:15 am.
This finding was reviewed with facility staff during the licensing inspection.
|
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 the quality of fire drills and ensuring they are conducted at different times per month. Each fire drill will be reviewed for quality assurance by DCO or designee. Facilities staff will be trained to change the times per month to ensure quality of fire drills.
3.) When will they be corrected (corrective action date)
Starting on 12/26/2023, staff will be trained on how to properly conduct a fire drill. Fire drill logs will be signed off for quality assurance by DCO.
4.) How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Director of Clinical Operations or designee will conduct monthly review of fire drill logs to ensure quality assurance. Facilities staff will be trained on conducting fire drills so that they are completed at different times every month.
|
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.
|
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 "first floor" as the exit route.
This finding was reviewed with facility staff during the licensing inspection.
|
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 the quality of fire drills and ensuring they are conducted at with use of different exit routes. Each fire drill will be reviewed for quality assurance by DCO or designee. Facilities staff will be trained to change the exit routes each month to ensure quality of fire drills.
3.) When will they be corrected (corrective action date)
Starting on 12/26/2023, staff will be trained on how to properly conduct a fire drill with different exit routes. Fire drill logs will be signed off for quality assurance by DCO.
4.) How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
The Director of Clinical Operations or designee will conduct monthly review of fire drill logs to ensure quality assurance of use of different exit routes. Facilities staff will be trained on conducting fire drills so that they are completed with different exit routes every month.
|
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.
|
Observations
Based on the review of client records, the facility failed to 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, purpose of disclosure.
Client #5 was admitted on June 15, 2023, and discharged on July 5, 2023. A consent to release form dated June 15, 2023, for an emergency contact, did not specify a purpose for the disclosure.
These findings were reviewed with facility staff during the licensing process.
|
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.
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.
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. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
Based on a review of partial client records, the facility failed to document treatment plan updates, in accordance with the facility's policy of every seven days, in two out of five applicable client records reviewed.
Client #8 was admitted on June 1, 2023, and was still active at the time of the inspection. A treatment plan update was completed on September 5, 2023, the next update was due no later than September 12, 2023; however, there was no subsequent update documented at the time of the inspection.
Client #13 was admitted on July 6, 2023, and was discharged on September 1, 2023. A comprehensive treatment plan was completed on August 1, 2023, and the next update was due no later than August 8, 2023; however, there was no update until September 1, 2023.
These findings were reviewed with facility staff during the licensing process.
|
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 complete an audit of treatment plan reviews monthly. Clinical staff will be trained on the frequency of treatment plan reviews.
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. Treatment plan review audits will also start in December.
4.) How will facility ensure the deficiency does not recur.
Director of Clinical Operations will conduct a randomized chart review of treatment plan reviews to ensure compliance starting 12/11/2023. Clinical staff will be trained in December and staff will be retrained as needed from chart audits. |
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of three applicable discharged record reviews.
The facility's policy notes that follow-up will be completed on each discharged client within 7 days, 30 days, 60 days, 90 days, 6 months and 1 year after discharge.
Client #5 was admitted on June 15, 2023, and was discharged on July 5, 2023. There was no documentation of a follow-up phone call or letter in the client's record.
Client #6 was admitted on July 18, 2023, and was discharged on August 25, 2023.There was no documentation of a follow-up phone call or letter in the client's record as per the facility's policy to contact the client 30 days post discharge.
Client #7 was admitted on July 3, 2023, and was discharged on September 1, 2023.There was no documentation of a follow-up phone call or letter in the client's record as per the facility's policy to contact the client 30 days after discharge.
This is a repeat citation from the October 19, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
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 conduct audits of discharged client charts to ensure policy and procedures are met for follow up.
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 charts will be audited to ensure compliance with standard on follow up of discharged clients.
4.) How will facility ensure the deficiency does not recur.
Director of Clinical Operations will conduct a randomized chart review of follow ups in discharged charts to ensure compliance starting 12/11/2023. |