INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 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 records.Employee # 4 is a counselor and was hired May 4, 2020. TB/STD training was not documented in personnel record # 4. Employee # 5 is a counselor and was hired October 13, 2020. HIV/AIDS training was not documented in personnel record # 5. 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 #4 is currently 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 #5 is currently signed up for Basic HIV occurring on January 10 and 11, 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 three of seven records.The facility billed for treatment services without written consent from the client in the following records.Client # 1 was admitted April 6, 2021.Client # 5 was admitted March 24, 2021 and discharged June 8, 2021.Client # 7 was admitted April 20, 2021 and discharged June 20, 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's #1 who is still enrolled in the JADE program will be contacted immediately to update consents.
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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 # 1 was admitted April 6, 2021. A consent for a family member did not include the dated signature of the client.Client # 3 was admitted May 26, 2021. A consent for a treatment provider did not include the dated signature of the client.Client # 7 was admitted April 20, 2021 and discharged June 20, 2021. Consents for a government agency, funding entity and social service provider 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.
Additionally, client #1, whom is still an active patient, will be contacted immediately for updated signatures on the consents.
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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 four of four records.No follow-up information was documented in the following client records:Client # 4 was admitted May 6, 2021 and discharged August 25, 2021.Client # 5 was admitted March 24, 2021 and discharged June 8, 2021.Client # 6 was admitted June 1, 2021 and discharged October 15, 2021.Client # 7 was admitted April 20, 2021 and discharged June 20, 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
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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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