This report is a result of an on-site licensure renewal inspection conducted on October 25, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Jade Wellness Services, 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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Observations
Based on one of three applicable client records reviewed, the facility failed to provide follow up documentation in accordance with the facility policy and procedure manual. The policy and procedure manual indicates follow up information to be completed within 7 days of discharge.
Client #5 was admitted on March 2, 2022 and was discharged on September 2, 2022. The follow up information was due to be completed no later than September 9, 2022, however, the follow up was not completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director has updated the follow up policy effective 12/01/2022 The policy now reads:
"Follow up phone calls will be made within 30 days of discharge date.
The Case Management Department and/or Certified Recovery Specialist are responsible to reach out to all clients discharged from treatment episode twice monthly on the 15th and 30th. Each member is to receive one follow up phone call and contact or lack-there-of will be documented in medical record file. It shall be the job of the facility director to do monthly audits of a sample of these discharges to ensure this is being done correctly and there are no future citations. Monthly audits will be conducted by pulling a discharge report from the previous month on the 1st of each following Month. Should the Facility Director not be able to conduct a monthly audit, the responsibility will fall to the Clinical Supervisor.
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