INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2021 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to document HIV/AIDS and TB/STD training in two of two personnel records.
Employee # 5 is a counselor and was hired May 12, 2020. HIV/AIDS and TB/STD training was not documented in personnel record # 5.
Employee # 6 is a counselor and was hired July 27, 2020. HIV/AIDS training was not documented in personnel record # 6.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New clinicians are required to receive core trainings, including HIV/ AIDS and TB/STD within 1 calendar year of being hired. Previously it was the job of the Facility Director to monitor each staff's progress sporadically throughout the calendar year. It will now be the job of the clinical supervisor(s) to revisit this monthly during supervision at each site, by getting out their training plan and seeing what has been accomplished to date, starting immediate in the New Year.
Employee number 5 is currently scheduled for BASIC HIV on January 10 and 11, 2022 and in the process for searching for TB/STD. It was decided by the clinical supervisor should TB/STD not be obtainable during the first quarter (03/31/2022) he will put on a 6-hour training for all new staff so we do not run into this issue in the future.
Employee #6 is currently looking for Basic HIV training openings and the Southside Clinical Supervisor is aware to keep track of this with her. |
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.
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Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in two of seven records.
The facility billed for treatment services without written consent from the client in the following records.
Client # 2 was admitted September 1, 2021.
Client # 7 was admitted April 15, 2021 and discharged October 28, 2021.
The findings were 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) During COVID-19 (from approximately March 20, 2020- December 1, 2021) we have allowed new patients to complete their LOCA over telehealth. Unfortunately, despite our best efforts clinicians and support staff were not collecting signatures on all of the consents in a timely fashion.
Effective immediate due to needing signatures on all of the consents we will no longer be allowing virtual LOCA'S. Any client looking to enroll in the JADE Program must come onsite to do so and sign all pertinent consents. Effective January 2, 2022, the Facility Director is responsible for ensuring all staff is aware of this new policy and all consents are obtained at time of service. 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.
Additionally, client #2 will be contacted immediately to ensure they give the proper signatures on their written consent forms.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the dated signature of the client in three of seven records.
Consents were documented during the intake process in the following client records.
Client # 2 was admitted September 1, 2021. Consents for a funding entity, pharmacy and probation did not include the dated signature of the client.
Client # 5 was admitted April 28, 2021 and discharged August 19, 2021. Consents for a treatment provider and probation did not include the dated signature of the client.
Client # 7 was admitted April 15, 2021 and discharged October 28, 2021. Consents for a funding entity, pharmacy, treatment provider and probation did not include the dated signature of the client.
The findings were 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) During COVID-19 (from approximately March 20, 2020- December 1, 2021) we have allowed new patients to complete their LOCA over telehealth. Unfortunately, despite our best efforts clinicians and support staff were not collecting signatures on all of the consents in a timely fashion.
Effective immediate due to needing signatures on all of the consents we will no longer be allowing virtual LOCA'S. Any client looking to enroll in the JADE Program must come onsite to do so and sign all pertinent consents. Effective January 2, 2022, the Facility Director is responsible for ensuring all staff is aware of this new policy and all consents are obtained at time of service. 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.
Client number 2 will be contacted immediately to ensure that they provide the proper signature on the written consent forms. |
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 follow-up information within seven days of discharge, per facility policy, in two of two records.
No follow-up information was documented in the following client records:
Client # 4 was admitted May 27, 2021 and discharged September 23, 2021.
Client # 7 was admitted April 15, 2021 and discharged October 28, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The JADE Wellness Center Facility Director has decided to update the current discharge policy to ensure future compliance effective immediately, 1/2/2022.
The policy shall now read:
"Follow up phone calls will be made within 30 days of discharge date.
The Case Management Department and/or Certified Recovery Specialist will reach 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. 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.
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