INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25, 2022, 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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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 seven 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 two of seven records.
The facility billed for treatment services without written consent from the client in the following records.
Client # 1 was admitted June 7, 2022 and was current at the time of the inspection.
Client # 5 was admitted June 14, 2021 and discharged September 15, 2021.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the licensing inspection on November 18, 2021.
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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). This includes consent to bill for treatment. This past year, 2021, we have seen more agency turn over in relation to administrative staff and feel despite our best-efforts, training for the level of care assessment process was not being followed when it came to obtaining written consents, such as billing for treatment services.
Effective immediate The Facility Director will be holding a MANDATORY training for all administrative/front desk personnel regarding the appropriate best practices for obtaining consents at time of LOCA. 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.
Client #1 who is still active in the program will be contact immediately by the Facility Director during the week of 12/1 to ensure they sign the appropriate documentation to get their chart compliant.
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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 one of three applicable client records reviewed, the facility failed to provide follow up documentation in accordance with the facility policy and procedure manual. The policy and procedure manual indicates follow up information to be completed within 7 days of discharge.
Client #6 was admitted on May 9, 2022 and was discharged on September 21, 2022. Follow up information was due to be completed no later than September 28, 2022, however, the follow up was not completed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from licensing inspection completed on November 18, 2021.
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Plan of Correction
The Facility Director has updated the follow up policy effective 12/01/2022. The policy now reads:
"Follow up phone calls will be made within 30 days of discharge date.
The Case Management Department and/or Certified Recovery Specialist are responsible to reach out to all clients discharged from treatment episode twice monthly on the 15th and 30th. Each member is to 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. Monthly audits will be conducted by pulling a discharge report from the previous month on the 1st of each following Month. Should the Facility Director not be able to conduct a monthly audit, the responsibility will fall to the Clinical Supervisor.
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