INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19-20, 2025, 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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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to provide a ventilated toilet and washrooms by exhaust fan or window.
Men ' s bathroom by group room #2 did not have an operational exhaust fan and or a window available.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Facilities Director
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Facilities Director will replace exhaust fan in Men's Bathroom by group room #2.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform monthly environment of care audits to ensure all bathroom fans are operational. If found to be not operational, a ticket will be created by e-mail to Facilities Director. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of fire extinguishers upon staff employment in one out of eleven records reviewed.
Employee #7 was hired as a counselor on April 15, 2025 and is still current in that position. Employee #7 was to be instructed in the use of a fire extinguisher upon employment but was not trained until May 5, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Director of Clinical Operations
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Director of Clinical Operations will run audits on all new employees to ensure fire safety training is being completed at hire.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform audits on all new employees to ensure fire safety training is being completed at hire. DCO will utilize Relias to assist with tracking of due dates for fire safety training. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in one out of eleven records reviewed.
Employee #7 was hired as counselor on April 15, 2025 and is still current in that position. Employee #7 was to be trained to perform assigned tasks during emergencies prior to working a shift. Documentation in the records shows the training did not occur until May 5, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Director of Clinical Operations
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Director of Clinical Operations will run audits on all new employees to ensure emergency procedures training is being completed at hire.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform audits on all new employees to ensure emergency procedures training is being completed at hire. DCO will utilize Relias to assist with tracking of due dates for emergency procedures training. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the person, agency, or organization to whom disclosure is made to in one of fourteen client records reviewed.
Client #7 was admitted to the partial hospitalization level of care on March 3, 2025 and was discharged on April 2, 2025. A release of information form was completed on March 3, 2025, that only identified " Insurance, " it did not include the person, agency, or organization it was for.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Director of Clinical Operations
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Director of Clinical Operations will run monthly audits on consent forms to ensure accuracy.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform monthly on all consent forms to ensure accuracy. DCO will complete a training quarterly on consent accuracy for all employees starting in December. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one of fourteen client records reviewed.
Client #5 was admitted to the partial hospitalization level of care on May 22, 2025 and was discharged on June 20, 2025. A release of information form for Quest labs, signed by the client on May 23, 2025, did not specify the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Director of Clinical Operations
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Director of Clinical Operations will run monthly audits on consent forms to ensure accuracy.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform monthly on all consent forms to ensure accuracy. DCO will complete a training quarterly on consent accuracy for all employees starting in December. |
709.83(a)(11) LICENSURE Client records
709.83. 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 partial hospitalization client records and the facility policy manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within 7 days, 30 days, 60 days, 6 months and one year, per facility policy, in three of four applicable records reviewed.
Client # 4 was admitted to the partial hospitalization program on April 17, 2025 and was discharged on June 5, 2025. The record did not contain documentation of follow-up information.
Client #5 was admitted to the partial hospitalization program on May 22, 2025 and was discharged on June 20, 2025. The record did not contain documentation of follow-up information.
Client # 6 was admitted to the partial hospitalization program on July 28, 2025 and was discharged on August 30, 2025. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Director of Clinical Operations
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Director of Clinical Operations or Quality Assurance Assistant will run monthly audits for follow up notes.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform audits on all clinical charts to ensure follow up notes are being completed in a timely manner. Director of Family and Alumni Program will be trained on completing follow up notes in a timely manner. |
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 outpatient client records and the facility policy manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within 7 days, 30 days, 60 days, 6 months and one year, per facility policy, in two of three applicable records reviewed.
Client # 11 was admitted to the outpatient program on March 24, 2025 and was discharged on July 16, 2025. The record did not contain documentation of follow-up information.
Client #13 was admitted to the outpatient program on August 4, 2025 and was discharged on September 16, 2025. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Who will correct the deficiency (job title, not name)
- Director of Clinical Operations
- 2. How the deficiency will be corrected (staff meeting, training, etc.)
- Director of Clinical Operations or Quality Assurance Assistant will run monthly audits for follow up notes.
- 3. When will they be corrected (corrective action date)
- 12/15/2025
- 4. How will the facility ensure the deficiency does not recur (periodic training, chart reviews, etc)
- Director of Clinical Operations or Quality Assurance Assistant will perform audits on all clinical charts to ensure follow up notes are being completed in a timely manner. Director of Family and Alumni Program will be trained on completing follow up notes in a timely manner. |