INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23, 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 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:
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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 a review of the personnel records, the facility failed to document that a counselor assistant had close supervision for six months.
Employee #11 was hired on July 22, 2021, as a counselor assistant with a bachelor's degree which requires her to have close supervision for the first six months of her employment. The facility did not ensure that employee #11 had close supervision in the month of September 2021, there was only two weeks of close supervision in November 2021 and only three weeks in December 2021.
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
Chief Clinical Officer
2.How the deficiency will be corrected (staff meeting, training, etc.)
Chief Clinical Officer met with the therapist who monitor counselor assistance and reviewed with them the required documentation for counselor assistants.
3.When they will be corrected (corrective action date)
All therapist who supervise counselor assistance signed a form that they understand the required documentation needed for counselor assistance.
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Quarterly audits of the supervision chart |
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 the 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 the client records in one out of seven client records reviewed.
Client #3 was admitted on March 5, 2022 and was an active client as of the date of inspection. A consent to release information form was signed and dated on March 10, 2022 to a government agency that allowed for the release of participation and attitude toward treatment, treatment goals, and recommendations.
These findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
1. Who will correct the deficiency
Chief Clinical Officer
2.How the deficiency will be corrected (staff meeting, training, etc.)
Chief Clinical Officer had a training on 4/6/2022 with all clinical, medical, admissions and case management staff. The staff were trained and shown examples of how to properly fill out the consents.
All current clients as of 4/12/2022 had consents audited. Any consent that was not valid was redone.
3.When they will be corrected (corrective action date)
All consents that needed to be redone will be completed by end of business 4/15/2022.
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit
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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 the client records, the facility failed to document a completed consent to release information form, as the forms were missing whether a copy had been offered to the client, in three out of seven client records reviewed.
Client #2 was admitted on March 3, 2020 and was still active at the time of the inspection. There were seven consent to release information forms signed and dated on March 3, 2022 to the funding source, medical providers, and emergency contact.
Client # 3 was admitted on March 5, 2022 and was still active at the time of the inspection. There were nine consents to release information forms signed and dated on March 5, 2022 for the funding source, medical providers, emergency contact and family members and one consent to release information form signed and dated on March 7, 2022 for a medical provider.
Client #4 was admitted on November 8, 2021 and discharged on December 17, 2021. There was one consent to release information form signed and dated on December 13, 2021 for a drug and alcohol facility and one consent to release information form signed and dated on November 26, 2021 for a family member.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Who will correct the deficiency
Chief Clinical Officer
2.How the deficiency will be corrected (staff meeting, training, etc.)
Chief Clinical Officer had a training on 4/6/2022 with all clinical, medical, admissions and case management staff. The staff were trained and shown examples of how to properly fill out the consents.
All current clients as of 4/12/2022 had consents audited. Any consent that was not valid was redone.
3.When they will be corrected (corrective action date)
All consents that needed to be redone will be completed by end of business 4/15/2022.
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit
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