INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 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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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 and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment in one of two records.
Employee #8 was hired as a counselor on May 12, 2020 and was still in this position at the time of the inspection. Employee # 8 was due to have the communicable disease trainings no later than May 12, 2021. No documentation was provided that staff #8 had completed at least 4 hours of TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the November 19, 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 comply with all licensing requirements, including, but not limited to staff training.
In recent years due to COVID 19 we have struggled with getting full staff completion on certain trainings due to them not being offered virtually. In this specific instance, BASIC-HIV. Effective immediately, 11/22/2024, in an effort to not be deficient for this we have obtained the curriculum for any trainings, including BASIC HIV, that are not currently offered remote so we may train employees during their shifts for things they may be in jeopardy of being delinquent of.
Furthermore, in an effort to not have staff delinquent on any training, we have added a training review template the agency staff supervision form. All clinical staff are supervised 1 on 1 a minimum of once monthly. During this time, it will be the job of the JADE clinical supervisor to review and document review of completion of all required trainings and a timeline to do so.
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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 off a review of personnel records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for ensuring that staff persons receive a minimum of at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the regulatory timeframe were submitted and approved by the Department for the November 19, 2021 and the October 25, 2022 annual licensing inspections. Ensuring that staff persons receive a minimum of at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the regulatory timeframe was again found to be a deficiency in the October 16, 2023 licensing inspection.
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 comply with all licensing requirements, including, but not limited to staff training.
In recent years due to COVID 19 we have struggled with getting full staff completion on certain trainings due to time conflicts, in this specific instance, TB/STD. Effective immediately, 11/22/2024, in an effort to not be deficient for this we have obtained the curriculum for any trainings, including BASIC HIV, that are not currently offered remote so we may train employees during their shifts for things they may be in jeopardy of being delinquent of.
Furthermore, in an effort to not have staff delinquent on any training, we have added a training review template the agency staff supervision form. All clinical staff are supervised 1 on 1 a minimum of once monthly. During this time, it will be the job of the JADE clinical supervisor to review and document review of completion of all required trainings and a timeline to do so.
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