This report is a result of a complaint investigation conducted on September 14, 2020, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site investigation, Pa Nice Homes 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 investigation and a plan of correction is required.
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Plan of Correction
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Observations
The facility failed to limit the provision of counseling services that are provided by the project staff to the physical address to which the license applies.
On September 14, 2020 staff from the Department jointly conducted an investigation along with staff from the Office of Mental Health and Substance Abuse Services (OMHSAS), which included staff and client interviews and review of clinical documentation.
It was determined that project clinical staff are on-site at a location that is not licensed by the Department or OMHSAS, and that clinical services are being provided at that location.
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Plan of Correction
1.Who will correct the deficiency (job title, not name)
Director of Program Operations and Compliance
2.How the deficiency will be corrected (staff meeting, training, etc.)
Email sent to all staff on 10/15/2020, staff meeting with the clinical team on 10/15/2020, and all clinical team members will sign off they understand that no clinical sessions are held at any location outside of the DDAP licensed facility location. Clinical staff will also not be permitted to the Inn without prior approval from there supervisor and if they don't follow this directive they could be disciplined, up to and including discharge/termination.
3.When they will be corrected (corrective action date)
10/15/2020
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Director of Program Operations and Compliance will complete chart reviews, remind staff periodically in weekly clinical meetings.
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