INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2023 and October 18, 2023 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 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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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information, which includes specific information disclosed, in one of seven records.
Client # 3 was admitted to the outpatient level of care on June 26, 2023 and discharged August 11, 2023. A release of information for an emergency contact was signed by client #3 on June 26, 2023 but did not indicate specific information to be disclosed.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record is always obtained during time of LOCA (level of care assessment).
Effective 12/1/2023 the Facility Director shall inform all staff whos position make it necessary to complete consent on the importance of completing the entire consent and indicating what specific information be disclosed.
Additionally, the Facility Director, with assistance from the JADE quality assurance specialist, will do monthly chart audits of all new patients to ensure consents are being signed and the new plan is being carried through.
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709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include an Aftercare Plan, in two of three records.
Client #1 was admitted to the outpatient level of care on March 7, 2023 and was successfully discharged July 14, 2023. No aftercare plan was documented in Client #1 ' s record.
Client #4 was admitted to the outpatient level of care on January 17, 2023 and successfully discharged May 17, 2023. No aftercare plan was documented in Client #4 ' s record.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
It is the policy of JADE Wellness Center to document an aftercare plan in each client discharge, whether successfully or involuntarily.
Effective 12/1/2023 JADE Wellness Center Facility Director has created a new aftercare/ relapse prevention form specifically for successful discharges. It is the job of all JADE counselors to complete this new form on all successful discharges. The discharge summary will automatically prompt therapist to complete said document should they have not already completed it at time of discharge.
It will be the job of JADE Clinical Supervisor to review all discharges for each caseload a minimum of once monthly, during supervision, to ensure the forms accurate completion. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in two of two records.
The facility policy states follow-up information should be documented no more than thirty-days post discharge.
Client #1 was admitted to the outpatient level of care on March 7, 2023 and discharged July 14, 2023. Follow-up information should have been documented no later than August 14, 2023. There was no follow-up information documented at the time of the inspection.
Client #4 was admitted to the outpatient level of care on January 17, 2023 and discharged May 17, 2023. Follow-up information should have been documented no later than June 17, 2023. There was no follow-up information documented at the time of the inspection.
These finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the November 18, 2021 and October 25, 2022 annual licensing renewal inspections.
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Plan of Correction
It is the policy of JADE Wellness Center to document follow up phone call with clients within 30 days of phone call.
The current deficiency is due to staff making the phone call but not documenting their work. In order to overcome this deficiency, the agency Facility Director will add, effective, 12/1/2023, a "follow up phone call" radio button to the discharge summary. This button must have an answer chosen, if yes, it will prompt a date for the phone call.
As per the previous deficiency, when the Clinical Supervisor completes supervision with clinical staff, a minimum of once a month they will review the discharges from caseload. At that time, they will spot check to ensure the follow up phone call was documented. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for documenting follow-up information in the client record were submitted and approved by the Department for the November 18, 2021 and the October 25, 2022 annual licensing inspections. Documenting follow-up information in the client record was again found to be a deficiency in the October 17, 2023 to October 18, 2023 licensing inspection.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Due to repeat deficiencies, The JADE Wellness Center Facility Director has decided to update the current discharge policy to ensure future compliance. This change took place 1/1/2023.
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The policy now read:
"Follow up phone calls will be made within 30 days of discharge date.
The Case Management Department and/or Certified Recovery Specialist were responsible for reaching out to all clients discharged from treatment episode twice monthly on the 15th and 30th. Each member will receive one follow up phone call and contact or lack-there-of will be documented in medical record file.
Due to a third deficiency it is observed while we at JADE Wellness Center are confident the follow up calls are happening; the documentation is not. Effective 1/1/2024 the CRS and Case Management Department will be having an in-service on the importance of this requirement.
Additionally, effective 12/1/2023 the Clinical Supervisor will not be responsible for spot checking this in a sample weekly during supervision with staff.
Any staff identified as continuing to not document the follow up calls will be written up according to agency policy. |