INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 6-7, 2014 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.
|
Plan of Correction
|
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on a review of client records, the facility failed to provide to the client on a regular and scheduled basis individual counseling, at least twice weekly, in two of five partial hospitalization client records.
The findings include:
Five partial hospitalization client records were reviewed on November 6 - 7, 2014. Five partial clients were required to receive individual counseling, at least twice weekly. The facility failed to provide to the client on a regular and scheduled basis individual counseling, at least twice weekly, in client records # 1 and 2.
Client # 1 was admitted into the partial hospitalization activity on March 10, 2014 and discharged on May 16, 2014. Client # 1 was only provided with one individual counseling session per week during this time period. The facility failed to provide individual counseling, at least twice weekly, to client # 1.
Client # 2 was admitted into the partial hospitalization activity on January 27, 2014 and discharged on April 17, 2014. Client # 2 was only provided with one individual counseling session per week during this time period. The facility failed to provide individual counseling, at least twice weekly, to client # 2.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
It will be the job of the JADE Wellness Center clinical supervisor to meet with the partial hospitalization staff and retrain them on the necessity of 2 individual sessions being scheduled weekly for all partial hospitalization clients. The Clinical Supervisor will also do a monthly random chart audit, for a minimum of 6 months following the date of citation, on all partial hospitalization clients to ensure that two weekly individuals are being performed on all clients in the Partial program. |
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:
|
Observations
Based on a review of client records, the facility failed to obtain a written, informed and voluntary consent form from the client prior to the disclosure of information contained in nine of seventeen client records.
The findings include:
Seventeen client records were reviewed on November 6 - 7, 2014. Seventeen client records were reviewed for written, informed and voluntary consent to release information forms. The facility failed to obtain a written, informed and voluntary consent form from the client prior to disclosing information to the insurance company for prescription authorization in client records # 1, 4, 5, 6, 7, 14, 15, 16 and 17.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will be responsible for re-training all clinicians and front desk staff on filling out written, informed and voluntary consents properly, with an emphasis on the insurance company for prescription medication. The clinical supervisor will do a monthly chart audit, for a minimum of 6 months following the date of citation, to ensure written, informed and voluntary consent for insurance companies are being done. |