INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19 - 20, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jade Wellness Center, LLC 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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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative materials, the project failed to document an annual audit of financial activities associated with the project's drug/alcohol abuse services for the fiscal year ended December 31, 2012.
The findings include:
A review of administrative materials was conducted on December 19, 2013. The project's fiscal year is from January through December. The project failed to document an annual audit of financial activities for the fiscal year January 1 through December 31, 2012. The Vice President of the facility confirmed an annual fiscal audit was not yet completed for the 2012 fiscal year.
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Plan of Correction
JADE Wellness Center's Vice President will take over the responsibility of working with a certified third party accountant in order to ensure a 2012 fiscal audit is completed. It will be the job of the Vice President to work with said accountant to ensure both 2012 as well as 2013 fiscal audits are completed prior to June of 2014. |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when disclosing client information to an employer in one of twelve client records. In addition, the facility failed to obtain a written consent from the client that included the specific information to be released in nine of twelve client records
The findings include:
Fifteen client records were reviewed on September 23 - 24, 2013. Twelve client records were reviewed for written consents to release information from the client. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 when releasing information to an employer in client record # 13. The facility failed to obtain a written consent from the client that included the specific information to be released to the emergency contact in client records # 1, 3, 4, 5, 6, 10, 11, 12 and 15.
Client # 13 was admitted into treatment on April 23, 2013. A consent to release information to the employer, dated April 23, 2013, indicated the client's progress and prognosis would be released to the employer. Client record # 13 included a letter to the employer dated May 21, 2013. The letter to the employer included the client's diagnosis, prognosis and progress in treatment. This exceeded the limitations imposed at 4 Pa. Code 255.5 which states information released to an employer shall be limited to whether the client has or is receiving treatment with the project.
The Vice President and lead counselor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
It shall be the job of the JADE Wellness Center Operations Manager in conjunction with the lead supervisor to ensure all JADE personnel remain compliant with 4 Pa. Code 255.5 when releasing information. It will be the job of the JADE lead supervisor to perform an in house training in 2014 refreshing all staff on code 255.5 and stress the importance that the only information to be released to an employer is whether the client has or is in treatment and may only be released with a consent in place. It will be the job of the JADE Operations manager to update all JADE consents to better identify the specific information to be released and go over these updates with all clinical staff during said training. The operations manager will make sure these new consents are correctly completed for the clients identified in the citation and do random quality assurance checks on all new client charts to release information and ensure this deficiency does not happen a second time. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility's physician failed to document in the patient's record the basis for the determination of current dependency in six of seven patient records.
The findings include:
Fifteen client records were reviewed on December 19 - 20, 2013. Seven patients were prescribed Suboxone. These patient records were reviewed for documentation that the physician made a face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment and the basis for this determination. The physician failed to document in the patient's record the basis for determination of current dependency in patient records # 5, 6, 9, 12, 13 and 15..
Patient # 5 was admitted into treatment on May 28, 2013. The physician conducted a face-to-face visit with patient # 5 on May 29, 2013 and prescribed 8 mg/2 mg Suboxone daily. The physician failed to document whether patient # 5 was currently physiologically dependent upon a narcotic drug prior to admission for maintenance treatment and the basis for the determination.
Patient # 6 was admitted into treatment on July 23, 2013. The physician conducted a face-to-face visit with patient # 6 on July 24, 2013 and prescribed 8 mg/2 mg Suboxone daily. The physician failed to document whether patient # 6 was currently physiologically dependent upon a narcotic drug prior to admission for maintenance treatment and the basis for the determination.
Patient # 9 was admitted into treatment on May 28, 2013. The physician conducted a face-to-face visit with patient # 9 on May 29, 2013 and prescribed 2 mg/.5 mg Suboxone daily. The physician failed to document whether patient # 9 was currently physiologically dependent upon a narcotic drug prior to admission for outpatient detoxification treatment and the basis for the determination.
Patient # 12 was admitted into treatment on April 30, 2013. The physician conducted a face-to-face visit with patient # 12 on May 1, 2013 and prescribed 8 mg/2 mg Suboxone daily. The physician failed to document whether patient # 12 was currently physiologically dependent upon a narcotic drug prior to admission for maintenance treatment and the basis for the determination.
Patient # 13 was admitted into treatment on April 23, 2013. The physician conducted a face-to-face visit with patient # 13 on April 24, 2013 and prescribed 4 mg/1 mg Suboxone daily. The physician failed to document whether patient # 13 was currently physiologically dependent upon a narcotic drug prior to admission for maintenance treatment and the basis for the determination.
Patient # 15 was admitted into treatment on July 2, 2013. The physician conducted a face-to-face visit with patient # 15 on July 12, 2013 and prescribed 8 mg/2 mg Suboxone daily. The physician failed to document whether patient # 15 was currently physiologically dependent upon a narcotic drug prior to admission for maintenance treatment and the basis for the determination.
The Vice President and Operations Manager were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the December 19 - 20, 2012 licensing inspection.
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Plan of Correction
It will be the job of the JADE Operations Manager to revise the JADE History and Physical form in order to separate the face to face basis for determination of physiologically dependence, for those clients being prescribed Suboxone, into two separate sections. It will be the job of the Operations Manager to ensure one section of the History and Physical form specifically asks for the physician to check off or write the basis of current physiological dependency upon a narcotic drug. It will be the job of the operations manager to ensure a separate section asks the physician to check off or write the basis of at least one year prior to admission of physiological dependency upon a narcotic drug. It will be the job of the Operations Manager to orient all JADE physicians and medical staff to this new form to ensure correct completion. Furthermore, it will be the job of the Operations Manager and Medical staff to spot check the physicians work from time to time to verify they are correctly completing both sections of the new form in order to prevent this citation from ever happening again. |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on a review of patient records, the facility's physician failed to adhere to the dosing protocol listed on the medication by ordering that single dose Suboxone film be halved and quartered in one of six patient records. The medication packaging identifies this as a single dose medication.
The findings include:
The physician prescribed Suboxone 2 mg/.5 mg SL film, 1.5 mg daily (3/4 film daily) for patient # 9 on October 20, 2013. The physician prescribed Suboxone 2 mg/.5 mg SL film, 1 mg daily (1/2 film daily) for client # 9 on November 20, 2013. The physician also prescribed Suboxone 2 mg/.5 mg SL film, .5 mg daily (1/4 film daily) for client # 9 on December 11, 2013.
Suboxone film is not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 12 mg/3 mg, 8 mg/2 mg, 4 mg/1 mg or 2 mg/.5 mg doses.
The Vice President and Operations Manager were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Operations Manager of JADE Wellness Center has reviewed this recurring issue with JADE Medical Director and reiterated the Suboxone Film is never to be cut. Any Suboxone prescription a JADE physician issues can only be written following the manufactured quantities of 12mg, 8mg, 4mg or 2mg. The operations Manager will continually review this topic with the JADE physicians as well as conduct Quality Assurance checks prior to clients leaving with Suboxone prescriptions. The Quality Assurance checks will ensure the JADE physicians are adhering to manufacturers recommendations and prevent the citation from happening again. |