INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20, 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 one of one personnel record.
Employee # 9 is a counselor and was hired May 15, 2020. HIV/AIDS and TB/STD trainings were not documented in personnel record # 9.
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 #9 is currently schedule for Basica HIV on January 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.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on December 20, 2021, the facility failed to ventilate bathrooms by exhaust fan or window.
The men's and women's bathrooms are located in front of the receptionist area of the facility. These bathrooms do not have windows and the exhaust fans located in the bathrooms were observed to not be operative.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During a minor bathroom remodel the light fixtures were changed out in the men's and women's bathrooms. It was found that the ventilation was never re-attached when completed.
Clinical Supervisor is to contact a electrician to come out and ensure the ventilation is properly re-hard wired to the new lights in the men and women's Monroeville bathrooms no later than 1/15/2022. |
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 five of seven records.
The facility billed for treatment services without written consent from the client in the following records.
Client # 1 was admitted May 5, 2021.
Client # 2 was admitted September 24, 2021.
Client # 3 was admitted August 23, 2021.
Client # 6 was admitted May 12, 2021 and discharged October 12, 2021.
Client # 7 was admitted May 19, 2021 and discharged October 29, 2021.
The findings were reviewed with 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.
Clients #1, 2 & 3 who are still active in the program will be contact immediately by the Facility Director during the week of 1/6 to ensure they sign the appropriate documentation to get their chart compliant.
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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 one of seven records.
Consents were documented during the intake process in the following client record.
Client # 3 was admitted August 23, 2021. Consents for insurance, pharmacy and a social service provider did not include the dated signature of the client.
The findings were reviewed with 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 #3 will be contacted by the Facility Director no later than 1/6 to ensure they sign the appropriate insurance, pharmacy and social service authorization to bring their chart into compliance.
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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 three of three records.
Client # 4 was admitted July 8, 2021 and discharged October 5, 2021. No follow-up information was documented.
Client # 6 was admitted May 12, 2021 and discharged October 12, 2021. No follow-up information was documented.
Client # 7 was admitted May 19, 2021 and discharged October 29, 2021. Follow-up information was not documented until December 15, 2021.
The 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 12/31/2021. 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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