INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3 & 4, 2021 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, AKA 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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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility's fire drill logs from November 2020 through October 2021, the facility failed to ensure that a smoke detector or fire alarm was set off during monthly fire drills.
These finding were reviewed with the 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 Clinical Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
A letter was sent to DDAP on 11/3/2021 requesting an exception to regulation 705.28 (d) (7) due to sharing the building with a dialysis and cardiologist facility. Setting off the fire alarm and/or smoke detector would disrupt the individuals providing and seeking services and the other medical facilities. Until the exception is approved the facility will purchase an air horn and will use this in the mean time.
3.When they will be corrected (corrective action date)
Air Horn has been purchased 11/11/2021 and will be delivered by 11/15/2021. Will use with all fire drills moving forward.
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Director of Clinical Operations will make sure all staff are aware of new procedure and train all incoming staff. |
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 on an
informed and voluntary consent to release information form the name of the person, agency, or organization to whom disclosure is made on one out of seven client records reviewed.
Client #4 was admitted on April 10, 2021 and discharged on June 16, 2021. A consent to release information was dated April 10, 2021 for the funding source.
These finding were reviewed with the facility staff during the licensing process.
This is a repeat violation from January 11 - 12, 2021 annual 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 Clinical 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)
11/9/2021
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 two out of the nine records reviewed.
Client #4 was admitted on April 10, 2021 and discharged on June 16, 2021. A consent to release information was dated April 10, 2021 for two medical facilities, two relatives, the funding source and a social service agency.
Client #5 was admitted on June 23, 2021 and discharged on August 6, 2021. Three consent to release information was dated June 23, 2021 for a medical facility, a relative and a funding source.
These finding were reviewed with the facility staff during the licensing process.
This is a repeat violation from January 11 & 12, 2021 annual 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 Clinical 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)
11/9/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit |
709.82(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of the client records, the facility failed to ensure that a comprehensive treatment plan included proposed type of service on seven out of seven client records reviewed.
These finding were reviewed with the 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 Clinical Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Clinical Operations updated the Master (Comprehensive) Treatment Plan and Treatment Plan to included the proposed type of service.
Staff were then trained on the updates
3.When they will be corrected (corrective action date)
11/9/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit |
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.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory time frame in accordance with the project's policy and procedures manual of every seven days in seven out of seven client records reviewed.
These finding were reviewed with the 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 Clinical Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Clinical Operations had a training with all clinical staff on when treatment plan reviews need to be completed.
3.When they will be corrected (corrective action date)
11/9/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of the client records, the facility failed to ensure that a comprehensive treatment plan included a proposed type of service in seven out of seven client records reviewed.
These finding were reviewed with the 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 Clinical Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Clinical Operations updated the Master (Comprehensive) Treatment Plan and Treatment Plan to included the proposed type of service.
Staff were then trained on the updates
3.When they will be corrected (corrective action date)
11/9/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of the client records, the facility failed to ensure that treatment and rehabilitation plans shall be reviewed and updated within the regulatory time frame in accordance with the project's policy and procedures manual of every fourteen days in seven out of the seven client records reviewed.
These finding were reviewed with the 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 Clinical Operations
2.How the deficiency will be corrected (staff meeting, training, etc.)
Director of Clinical Operations trained the staff on the time frames of when treatment plan reviews need to be completed.
3.When they will be corrected (corrective action date)
11/9/2021
4.How the facility will ensure the deficiency does not recur (periodic training, chart reviews, etc)
Monthly consent audit |