INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14 - 15, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jade Wellness Center, 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(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of the facility's policy and procedure manual and staff training records, the facility failed to document an assessment of staff training needs, as per facility policy.
The findings include:
The facility's policy and procedure manual and staff training records were reviewed on December 14, 2011. The facility policy titled "Staff Development Program", dated April 5, 2010, states the following:
"Assessment of needs will include a combination of individual supervisory meetings, and questionnaires and/or group discussion of training needs and interests and will be completed by December 31 of each year. A written summary of the results of training assessments will be documented and shall serve to guide the training content of the staff development program for the next year. This shall be completed by December 31 of each year."
An assessment of staff training needs was due to be completed no later than December 31, 2010 for the January 1 - December 31, 2011 training year.
Staff training record # 1 included a list of training needs dated January 5, 2011.
Staff training record # 6 included a list of training needs dated January 25, 2011.
The facility failed to document an assessment of staff training needs that included a written summary by December 31, 2010, as per facility policy.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
704.11(a)(1) Training Needs Assessments:
Jade Wellness Center's Practice/Facility Director will revise the policy on staff development to reflect the new training year. The training plan year will be from January 1 to December 31. Practice/Facility Director will develop a written summary of all staffs needs based off of individual supervisor meetings and/or group meetings. Practice/Facility Director will then develop a written summary by January 31 of each year.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to document an annual evaluation of the overall training plan.
The findings include:
The facility's policy and procedure manual was reviewed on December 14, 2011. The facility policy titled "Staff Development Program", dated April 5, 2010, states the following:
"At the end of each training year, an annual evaluation will be made to determine what extent the plan addressed the identified needs as laid out in the initial assessment. This shall be completed by December 31 of each year."
An annual evaluation of the overall training plan was due to be completed no later than December 31, 2010 for the January 1 - December 31, 2010 training year. The facility failed to document an annual evaluation of the overall training plan by December 31, 2010, as per facility policy.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
704.11(a)(4) Evaluation of Overall Plan:
Jade Wellness Center's Practice/Facility Director will revise the policy on staff development to reflect the training year January 1 to December 31. Practice/Facility Director will develop an overall evaluation of the training plan by the end of the training year that ends on December 31.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill records, the facility failed to document the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative.
The findings include:
On December 15, 2011, the fire drill records were reviewed for November 2010 through November 2011. The fire drill record form has a space to document the number of staff and the number of clients present in the facility at the time of the fire drill. The facility failed to document the number of clients present in the facility at the time of the drill conducted on October 31 and November 23, 2011.
The facility failed to document whether the fire alarm or smoke detector was operative during the drill conducted on September 30, October 31 and November 23, 2011.
The Vice President of Operations and facility director were interviewed and confirmed the findings.
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Plan of Correction
705.28(d)(4) Fire Safety:
The Practice/Facility Director or Office Manager will be responsible to conduct monthly fire drills. Said staff will complete the Jade Wellness fire drill log during the fire drill. Said staff will insure that the form is filled out in it's entirely. The staff in charge will record the date, time, type of drill, number of persons participating in drill, who sounded the alarm, exit routes used, if the devices operated correctly, if problems occurred, smoke detectors checked and time of evacuation. The Practice/Facility Director and/or Office Manager will also sign the completed form to insure accuracy.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
On December 15, 2011, the fire drill records were reviewed for November 2010 through November 2011. The facility failed to set off a fire alarm or smoke detector during each fire drill conducted from November 2010 through November 2011.
The Vice President of Operations was interviewed on December 15, 2011 at approximately 1:30 PM and confirmed the facility had not set off a fire alarm or smoke detector during any of the fire drills conducted.
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Plan of Correction
705.28(d)(7) Fire Safety:
The Practice/Facility Director or Office Manager will set off the smoke detector during monthly fire drills to insure that the smoke detectors are operating correctly. This was instituted on 12/23/11 when Jade had a fire drill.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative policies and procedures, the project failed to complete the 2010 audit by the end of the project's fiscal year.
The findings include:
A review of administrative policies and procedures was conducted on December 14, 2011. The project's fiscal year is from January through December. The project failed to document the completion of an annual audit for the January through December 2010 fiscal year, as of December 14, 2011.
On December 14, 2011 at approximately 2:30 PM, the Vice President of Operations confirmed an annual audit had not been completed for the 2010 fiscal year.
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Plan of Correction
709.25(a) Fiscal Management:
On 12/21/11 a letter was submitted to the Department of Health Division of Drug and Alcohol requesting exemption of the annual fiscal audit. If this exemption is not granted to the Jade Wellness Center, the Vice President of Operations will insure that a fiscal audit for 2010 and 2011 will be completed by June 30 2012.
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in three of four personnel records.
The findings include:
Eight personnel records were reviewed on December 14, 2011. Annual staff work performance evaluations were required in four personnel records. Per facility policy, staff performance evaluations will be conducted annually by the employee's hire date. The facility did not document annual staff work performance evaluations in personnel records # 1, 7 and 8.
Employee # 1 is a co-owner. The facility began providing services on April 27, 2010. The annual work performance evaluation was due to be completed no later than April 27, 2011. The facility failed to document an annual work performance evaluation as of December 14, 2011.
Employee # 7 is a co-owner. The facility began providing services on April 27, 2010. The annual work performance evaluation was due to be completed no later than April 27, 2011. The facility failed to document an annual work performance evaluation as of December 14, 2011.
Employee # 8 was hired on March 11, 2010. The facility began providing services on April 27, 2010. The annual work performance evaluation was due to be completed no later than April 27, 2011. The facility failed to document an annual work performance evaluation as of December 14, 2011.
The Vice President of Operations was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
709.26(d)(5)(i) Personnel Management:
On 12/27/11 the Owner/CEO and Practice/Facility Director conducted annual performance evaluations on employees #1, 7 and 8. The Practice/Facility Director will be responsible to insure that annual performance evaluations are completed on all treatment staff members. The Owner/CEO will conduct the annual performance evaluations on herself and the Practice/Facility Director, Vice President of Operations and the Office Manager. The Vice President of Operations will be responsible for insuring that annual performance evaluations are completed for all other support staff. All annual performance evaluations will be completed prior to the anniversary date of hire.
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709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of medication storage area inspection logs and the facility's policy and procedure manual, the facility failed to document quarterly inspections of the medication storage area to ensure that these areas are maintained in compliance with federal, state and local regulations.
The findings include:
Medication storage area inspection logs and the facility's policy and procedure manual were reviewed on December 14 - 15, 2011. Per facility policy, medication storage areas will be inspected on a quarterly basis and will verify the following: disinfectants and drugs for external use are stored separately from oral and injectable drugs; drugs requiring special conditions for storage to insure stability are properly stored; outdated drugs are removed; administration of controlled drugs are adequately documented; controlled substances and other abusable drugs are stored in accordance with federal, state and program regulations; and copies of drug-related regulations are available in appropriate areas.
The facility conducted inspections of the medication storage area in March, June, September and December. It is not possible to determine the dates of the inspections; as they are not documented on the inspection log. The medication storage area inspection log includes documentation that controlled substances are stored in accordance with federal, state and program regulations. However, the facility failed to verify the following information on the inspection log: disinfectants and drugs for external use are stored separately from oral and injectable drugs; drugs requiring special conditions for storage to insure stability are properly stored; outdated drugs are removed; administration of controlled drugs are adequately documented; and copies of drug-related regulations are available in appropriate areas.
The facility director was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
709.32(c)(3) Medication Control:
On 12/19/11 The Practice/Facility Director changed the policy and procedures on the Inspection of Storage Areas. Per facility policy, medication storage areas will be inspected on a quarterly basis and will verify the following: disinfectants and drugs for external use are stored separately from oral and injectable drugs; drugs requiring special conditions for storage to insure stability are properly stored; outdated drugs are removed; administration of controlled drugs are adequately documented; controlled substances and other abusable drugs are stored in accordance with federal, state and program regulations; door locks operating correctly; cabinet locks operating correctly; lock box lock is operating correctly and copies of drug-related regulations are available in appropriate areas. On 12/19/11 the Practice/Facility Director also changed the quarterly inspection log to reflect the above mentioned criteria in order to meet the federal, state and local regulations. To ensure future compliance, once the nurse completes the quarterly inspection form, the Practice/Facility Director, Vice President of Operations or the Office Manager will also sign off indicating that the inspection has been done correctly.
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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records and the medication storage area, the physician failed to determine the proper dosage level for the patient.
The findings include:
The physician prescribed Suboxone 8 mg/2 mg film, 1 1/4 daily, for patient # 2 on November 29, 2011. Patient # 2 was also prescribed Suboxone 8 mg/2 mg film, 1 1/2 daily on December 3, 2011.
Suboxone film is not formulated to be cut into smaller doses. Prescriptions need to be for the manufactured quantities of 8 mg/2 mg or 2 mg/.5 mg doses. A 10 mg dose requires one prescription for 8 mg/2 mg film and a second for 2 mg/.5 mg film. A 4 mg dose requires the patient be given two 2 mg/.5 mg doses.
A prescription bottle for buprenorphine 8 mg tablet SL, 1/2 tablet, dated July 12, 2011, was stored in the medication area. Buprenorphine tablets are not formulated to be cut in half. Prescriptions need to be for the manufactured quantities of 2 mg or 8 mg tablets. A 4 mg dose requires that the patient be given two 2 mg pills.
Interviews with the facility director and Vice President of Operations confirmed the findings.
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Plan of Correction
715.15(b) Medication Dosage:
The Practice/Facility Director has discussed and reviewied with the Jade Wellness physicians that the Suboxone film is not formulated to be cut into smaller doses. Therefore any suboxone prescriptions that a Jade Wellness physician issues can only be written following the manufactured quanties of 8mg or 2mg. The Practice/Facility Director and/or Office Manager will ensure that the Jade physicians are adhering to the manufactures recommendations by conducting Quality Assurance checks of all written prescriptions during the medication visits prior to the client leaving Jade. |
715.17(a) LICENSURE Medication control
(a) A narcotic treatment program shall comply with applicable Federal and State statutes and regulations regarding the storing, compounding, administering and dispensing of medication.
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Observations
Based on a review of the medication storage area, the facility failed to comply with Federal regulations regarding the storing, compounding, administering and dispensing of medication.
The findings include:
The facility's medication storage area was inspected with the facility director on December 15, 2011 at approximately 9:30 AM.
A prescription bottle for buprenorphine 8 mg tablet SL, 1/2 tablet, dated July 12, 2011 was prescribed in the name of a facility employee. This is in violation of Federal regulations which require this prescription to be in the name of the patient or the prescribing physician.
A box of Suboxone film 2 mg/.5 mg was prescribed in the name of the facility. This is in violation of Federal regulations which require this type of prescription to be in the name of the patient or the prescribing physician.
The facility director was interviewed during the inspection of the medication storage area and confirmed the findings.
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Plan of Correction
715.17(a) Medication Control:
On 12/28/11, the Practice/Facility Director discussed with the Jade Wellness physicians that all medications ordered by Jade must be in the physician's name. On the above mentioned date new prescriptions were ordered by a Jade physician. Additionally, the new prescriptions were written in the name of the prescribing physician for induction use only. The physicians will follow the Federal regulations to ensure that prescriptions will be in the name of the client or the prescribing physician. To ensure that future medication continues to be written in this manor the Practice/Facility and or the Office Manager will oversee the ordering of all medication for the Jade Wellness Center. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in two of six client records.
The findings include:
Twelve client records were reviewed on December 15, 2011. Six client records included an individual treatment and rehabilitation plan and were reviewed for the type and frequency of treatment and rehabilitation services. The facility failed to document the type and frequency of treatment and rehabilitation services in client records # 4 and 5.
Client # 4 was admitted into treatment on April 20, 2011. An individual treatment and rehabilitation plan was developed with the client on May 10, 2011. Per review of the record or services provided, the client is participating in individual counseling sessions. The treatment plan did not specify the individual counseling sessions or the frequency of these sessions.
Client # 5 was admitted into treatment on May 19, 2011. An individual treatment and rehabilitation plan was developed with the client on June 20, 2011. The treatment plan indicated the client is participating in individual counseling sessions but did not specify the frequency of these sessions.
The facility director was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
709.92(a)(2) Treatment and Rehabilitation Services:
The Practice/Facility Director will ensure that the staff will document the types and frequencies of services on each of the client's comprehensive treatment plan. The Practice/Facility Director will conduct a staff meeting to reeducate the staff of the necessity of the comprehensive treatment plan reflecting the type and frequency of services that are being provided to the client. During random quality assurance chart reviews the Practice/Facility Director will check to insure that treatment plans reflect services and frequencies provided. The Practice/Facility Director will also sign off on all comprehensive treatment plans to insure compliance.
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709.93(a)(2) 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:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to document medication records which indicate the frequency of use in three of six client records.
The findings include:
Twelve client records were reviewed on December 15, 2011. Medication records which indicate the frequency of use were required in six client records. The facility did not document medication records which indicate the frequency of use in client records # 1, 6 and 12.
Client # 1 was admitted into treatment on April 26, 2011. Client # 1 is prescribed Clozaril 300 mg and Neurontin 1800 mg. The facility failed to document the frequency of these medications. The client was also prescribed Anafranil. The facility failed to document the dose or frequency of use of this medication.
Client # 6 was admitted into treatment on October 27, 2011. Client # 6 is prescribed Celexa 20 mg and Prilosec 20 mg. The facility failed to document the frequency of use of these medications.
Client # 12 was admitted into treatment on October 25, 2011 and discharged on December 7, 2011. Client # 12 was prescribed Vicodin 750 mg and Amoxicillin 1500 mg. The facility failed to document the frequency of use of these medications.
The facility director reviewed client records # 1, 6 and 12 on December 15, 2011 at approximately 3:45 PM and confirmed the findings.
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Plan of Correction
709(a)(2)Client Records:
On 12/27/11 The Practice/Facility Director added the category Frequency onto the Medication section of the Needs-Assessment form. The Practice/Facility Director will conduct a staff meeting to educate the staff of the necessity of including frequency of medication on the needs-assessment. During random quality assurance chart reviews the Practice/Facility Director will check to insure that Frequency of medication is being recorded correctly. The assigned counselor will obtain the dose and frequency of medications for client's # 1, 6 and 12 by January 31, 2012. The assigned counselor will record the client's responses in the margin of the Needs Assessment, next to the Medication section. The counselor will record this information with an ink pen. To ensure that the charts for client's #1, 6 and 12 are updated the Practice/Facility Director will conduct a random quality assurance check by January 31, 2012.
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