INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18 - 20, 2012 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of personnel records, the facility failed to document the required period of close supervision for one counselor assistant.
The findings include:
Nine personnel records were reviewed on December 18 - 19, 2012. One personnel record pertained to a counselor assistant and required documentation of close supervision. The facility failed to document close supervision for employee # 4.
Employee # 4 has been a counselor assistant since August 6, 2012. Employee # 4 has a Bachelor's degree in a related field. Employee # 4 required close supervision for the first six months of employment . The facility failed to provide documentation of close supervision for employee # 4.
The Vice President of Finance was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
JADE Wellness Center's Lead Counselor will take over the direct supervision of any counselors assistants beginning January 1st, 2013. It will be the job of the Lead Counselor to meet with the counselor assistant(s) on a weekly basis and provide the necessary documentation. The VP of Finance will create a supervision form for the Lead Counselor to use during weekly evaluations. It will be the job of Lead Counselor to collect and file these sheets as well as monitor and supervise all new counselor assistants hired in the future in the same manner as a means to prevent the citation from happening again. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the facility's policy and procedure manual and administrative materials, the governing body failed to make available to the public the 2011 annual report.
The findings include:
The facility's policy and procedure manual and administrative materials were reviewed on December 18, 2012. The facility is publicly funded and completed an annual report for January - December 2011. The governing body failed to make the 2011 annual report available to the public.
The Vice President of Finance was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
JADE Wellness Center's Vice President of Finance has already contacted the host of the JADE Wellness Center website (www.jadewellness.com), which is available to the public, and added the statement "annual report available upon request" to the bottom of the home screen. It is the responsibility of the VP of Finance to monitor the website to ensure that the annual report is always available to the public, in order to ensure the deficiency does not recur. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility's physician failed to document whether an individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment in two of five patient records.
The findings include:
Eighteen client records were reviewed on December 19 - 20, 2012. Five patients were prescribed Suboxone. These patient records were required to include documentation that the physician made a face-to-face determination of whether the individual was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment. The physician failed to document the patient's current physiological dependence and one year physiological dependence prior to admission for maintenance treatment in patient records # 7 and # 14.
Patient # 7 was admitted into treatment on September 27, 2012. The physician conducted a face-to-face visit with patient # 7 on October 5, 2012. The physician prescribed 8 mg/2 mg Suboxone daily on October 5, 2012. The physician failed to document whether patient # 7 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment.
Patient # 14 was admitted into treatment on August 10, 2012. The physician conducted a face-to-face visit with patient # 14 on August 11, 2012. The physician prescribed 8 mg/2 mg Suboxone daily on August 11, 2012. The physician failed to document whether patient #14 was currently physiologically dependent upon a narcotic drug and had been physiologically dependent for at least one year prior to admission for maintenance treatment.
The Vice President and Operations Manager were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
It will be the job of JADE Wellness Center's Operations Manager to revise the History and Physical form to reflect a determination to support physiologic dependence for a minimum of 1 year, as well as current physiologic dependence, and a basis for this determination by the Doctor by January 1st, 2013. The Operations manager will communicate this change to the Doctors no later than January 1st, 2013. The Operations Manager will go onto each JADE computer by January 1st, 2013 and delete any old forms immediately. The Lead Clinician will be doing monthly patient chart audits to ensure the appropriate forms are being completed correctly by the physicians to prevent this citation from recuring. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of two client records.
The findings include:
Eighteen client records were reviewed on December 19 - 20, 2012. Two client records were successful discharges and required documentation of an aftercare plan. Per facility policy, an aftercare plan will be completed prior to a successful discharge of a client. The facility failed to document an aftercare plan in client record # 16.
Client # 16 was admitted into treatment on August 9, 2011 and was successfully discharged on May 10, 2012. There was no documentation of an aftercare plan in client record # 16, as of December 20, 2012.
The Operations Manager and lead counselor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
JADE Wellness Center's Lead Clinician will hold an in house training during the first quarter of 2013 in order to reiterate the proper completion of an aftercare plan. The Lead Clinician will periodically audit discharge charts to ensure the aftercare plans are being completed successfully. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to comply with 55 Pa. Code Part III (relating to the Medical Assistance Manual) in three of three client records.
The findings include:
The regulation at 55 Pa. Code Part III chapter 1223.52 section (a) subsection 6 (i) - (ii) specifies that "within 15 days following intake, the clinic's supervisory physician shall review and verify each patient's level of care assessment, psychosocial evaluation and initial treatment plan prior to the provision of any treatment beyond the 15 th day following intake. The clinic's supervisory physician shall verify the patient's diagnosis. The clinic's supervisory physician shall sign and date the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis in the patient's record. Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic's supervisory physician shall review and update each patient's treatment plan. Each review and update shall be dated, documented and signed in the patient's record by the clinic's supervisory physician."
Eighteen client records were reviewed on December 19 - 20, 2012. Three client records pertained to clients receiving Medical Assistance benefits and required documentation of a physician's dated signature on the patient's level of care assessment, psychosocial evaluation, treatment plan, diagnosis and treatment plan updates. The facility failed to document a dated physician's signature on the patient's level of care assessment, psychosocial evaluation, treatment plan, diagnosis and treatment plan updates in client records # 3, 5 and 6.
Client # 3 was admitted into treatment on August 2, 2012. Intake paperwork including the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis were completed on August 2, 2012. This intake paperwork was due to be signed and dated by the physician no later than August 17, 2012. The physician signed but failed to date the intake paperwork. It was not possible to determine if the documents were signed within 15 days of intake. Treatment plan updates were completed on August 18 and October 18, 2012 and were signed by the physician but not dated.
Client # 5 was admitted into treatment on November 23, 2012. Intake paperwork including the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis were completed on November 23, 2012. This intake paperwork was due to be signed and dated by the physician no later than December 8, 2012. The physician signed but failed to date the intake paperwork. It was not possible to determine if the documents were signed within 15 days of intake.
Client # 6 was admitted into treatment on June 14, 2012. Intake paperwork including the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis were completed on June 14, 2012. This intake paperwork was due to be signed and dated by the physician no later than June 29, 2012. The physician signed but failed to date the intake paperwork. It was not possible to determine if the documents were signed within 15 days of intake. Treatment plan updates were completed on the following dates: June 20, August 14, October 13 and December 3, 2012. The physician signed but did not date these treatment plan updates.
The Vice President and lead counselor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
JADE Wellness Center's Operations Manager will edit all forms that require a Doctors signature, including the PCPC, psychosocial and treatment plans, to incorporate a spot for the date next to the physicians signature by January 1st, 2013. Beginning immediately, it will be the job of the Operations Manager with the help of the Lead Clinician to audit and ensure all documents signed by the physician are being dated correctly and in a timely manner. |