INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 13-14, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jade Wellness, 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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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
The facility failed to file an unusual incident report with the Department within 3 business days following the death of a client.Seven client records were reviewed on December 13-14, 2017. Client #6 was admitted on 4/24/17 and passed away in September 2017. At the time of the inspection, no unusual incident report had been sent to the Department.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It will be the job of the Clinical Supervisor to train each JADE staff member in regards to company protocol for following DDAP policy 709.34; reporting of unusual incidents. The Clinical Supervisor will hold a refresher training at each site reiterating what constitutes as an unusual incident and the ways to report said incident to the appropriate governing body. This will be done during the first month of the New Year 2018. |