INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18, 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 6 hours of HIV/AIDS training within the first year of employment in one of one record.
Employee #6 was hired as a counselor on June 14, 2022 and was still in this position at the time of the inspection. Employee # 6 was due to have the HIV/AIDS training no later than June 14, 2023. No documentation was provided that staff #6 had completed at least 6 hours of HIV/AIDS training as of the date of the inspection.
The findings were 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 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. |
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 a complete client record, which is to include an Aftercare Plan, in one of two records.
Client #5 was admitted to the outpatient level of care on April 5, 2023 and was successfully discharged September 13, 2023. No aftercare plan was documented in Client #5 ' s record.
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 document an aftercare plan in each client discharge, whether successfully or involuntarily.
Effective 12/1/2023 JADE Wellness Center Facility Director has created a new aftercare/ relapse prevention form specifically for successful discharges. It is the job of all JADE counselors to complete this new form on all successful discharges. The discharge summary will automatically prompt therapist to complete said document should they have not already completed it at time of discharge.
It will be the job of JADE Clinical Supervisor to review all discharges for each caseload a minimum of once monthly, during supervision, to ensure the forms accurate completion.
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