INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 24 -25, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 and training records, the facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in one of eight personnel records.
The findings include:
Eight personnel records were reviewed on October 2-3, 2012. Eight personnel records required documentation of HIV/AIDS and/or tuberculosis, sexually transmitted diseases and other health related topics training. Employees records # 2 and 3 did not include documentation of the completion of the required training.
Employee # 2 was hired on July 5, 2011. Tuberculosis and sexually transmitted diseases and other health related topics training was due to be completed by July 5, 2012. There was no documentation that the employee had completed the TB/STD training as of October 5, 2012.
The human resource staff was interviewed on October 3, 2012 and confirmed the findings.
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Plan of Correction
Employee #2 scheduled TB/STD training to be held December 10, 2012. Employee # 3 scheduled HIV/AIDS training to be held December 17, 2012 and TB/STD training to be held December 10, 2012. Both employees provided verification of training registration to Program Director.
Effective immediately, all counselors are to submit verification of training registration to Program Director.
Beginning October 22, 2012, Human resource coordinators will ensure that training evaluations for all trainings are placed in each individual's employee file. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director and the facility director in one of two personnel records.
The findings include:
Fifteen personnel records were reviewed on October 2-3, 2012. The facility's training year is January- December. The facility's 2011 training year was reviewed. Two personnel records required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since July, 1999. There were no training hours documented for the 2011 training year.
The human resource staff was interviewed on October 3, 2012 and confirmed the findings.
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Plan of Correction
Project Manager will complete the required 12 hours of training by Nov 30, 2012 . Copies of training certificates will be maintained within his personnel file as evidence of compliance. Human Resource Coordinator will monitor quarterly for ongoing compliance. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill record was reviewed on October 24, 2012. The fire drills conducted from November 2011 - September 2012 were reviewed. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility failed to address the alternative means of egress for all months reviewed.
An interview with the facility director on October 25, 2012 confirmed the findings.
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Plan of Correction
Form revised to appropriately document alternate exit routes during monthly random fire drills on 11/21/12
Program Director to monitor quarterly to ensure ongoing compliance.
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills are conduct on different times of the day.
The findings include:
Based on the review of the fire drill record, the facility failed to ensure that fire drills are conduct on different times of the day.
The findings include:
The fire drill record was reviewed on October 24, 2012. There was documentation of five fire drills that were conducted on the morning shift and six fire drills were documented during the afternoon shift, the latest drill occurred at 3:10 pm. The following months were reviewed November 2011, December 2011, January 2012, February 2012, March 2012, April 2012, May 2012, June 2012, July 2012, August 2012 and September 2012. The facility's hours are Monday through Thursday from 5:30 am to 7:30 pm, Friday from 5:30 am to 4 pm and Saturday/Sunday from 6 am to 10 am.
The facility director was interviewed on October 25, 2012 and she confirmed the findings.
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Plan of Correction
Program Director reviewed Fire Drill Procedures with York County Maintenance Supervisor on October 25, 2012 regarding conducting fire drills at different times of the day.
Program Director to monitor quarterly to ensure ongoing compliance.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtained informed and voluntary consents in five of sixteen client records.
Findings:
Sixteen client records were reviewed on October 24-25, 2012. Consent to release forms were required in sixteen records.
Client record #1 contained faxes, dated August 21, 2012, August 27, 2012, October 9, 2012 and October 15, 2012, that were sent to a government agency that had identifying information pertaining to client #1. The facility did not have a consent to release form that permitted this communication.
Client record #2 contained faxes, dated July 31, 2012, August 10, 2012, August 13, 2012, August 19, 2012, August 22, 2012, September 19, 2012, September 28, 2012, October 9, 2012, October 15, 2012, that were sent to a government agency that had identifying information pertaining to client #2. The facility did not have a consent to release form that permitted this communication.
Client record #5 contained a consent form, dated June 19, 2012, that did not document who was to receive the information, what was being released and the purpose of the release. A progress note, dated July 26, 2012, stated that the counselor met with the client to discuss a conversation between the counselor and mother pertaining to the client. A review of client #5's record revealed that there was no consent to release for the client's mother. Also, a consent to release dated June 19, 2012 did not document what was being released.
Client record #7 had a consent form, dated July 26, 2012, that did not document what was being released and the purpose for the release.
Client record #8 had 2 consents, dated July 3, 2012, that did not document who it was for, what is being release and the purpose for the release. Also, a consent to release to a government agency, dated July 3, 2012, failed to document whether the client received a copy the consent form.
Client record #14 had three consents, dated June 14, 2012, that failed to document if the client received a copy. A consent to release form, dated June 14, 2012, to a government agency exceeded 255.5 by allowing the client's history/physical, discharge summary/aftercare plan and MARS to be released to this government agency. Also, a consent to release on June 14, 2012 to a government agency did not include documentation if the client received a copy of the consent form.
An interview with the facility director on October 25, 2012 confirmed the findings.
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Plan of Correction
The program received revised consents for releasing substance abuse information on 10.18.12 from the VP of Clinical Services.
The revised forms were reviewed with and distributed to all clinical staff on 10.25.12.
Program Director will ensure compliance on the use of the correct forms and release of permitted information through monthly random chart audits.
The Corporate Compliance Officer will conduct quarterly compliance audits to further ensure adherence.
Clinical staff that were identified as being deficient will re-attend DDAP approved Confidentiality training at the next available and convenient offering.
Training attendance will be monitored by Human Resources through quarterly personnel review.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in ten of sixteen client records.
The findings include:
Sixteen client records were reviewed on October 24-25, 2012. all records were reviewed for psychosocial evaluations.
The psychosocial evaluations in client records #3, 4, 5, 6, 7, 8, 11, 12, 15 and 16 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #3, 4, 5, 6, 8, 11, 12, 15 and 16 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #4, 5, 6, 7, 8, 11, 12, 15 and 16 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #4, 5, 6, 7, 8, 11, 12, 15 and 16 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #3, 6, 11 and 14 did not include an evaluation of the counselor conclusions/impressions of the client.
Also, per the facility policy, psychosocial evaluations are to be completed within 30 days of the client's admission date.
Client #1 was admitted on August 1, 2012; the psychosocial evaluation was to be completed by September 1, 2012. At the time of the inspection, there was no documentation of client #1's psychosocial evaluation.
Client #9 was admitted on June 25, 2012 and discharged on August 2, 2012. The psychosocial evaluation was to be completed by July 25, 2012. At the time of the inspection, there was no documentation of client #9's psychosocial evaluation.
Client #10 was admitted on August 10, 2012 and discharged on October 11, 2012. The psychosocial evaluation was to be completed by September 10, 2012. At the time of the inspection, there was no documentation of client #10's psychosocial evaluation.
An interview with the facility director on October 25, 2012 confirmed the findings.
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Plan of Correction
All counselors were provided informative packets on November 1, 2012 regarding Clinical Impressions of the psychosocial evaluation and necessary areas that are required including counselor signature and date. All counselors will sign acknowledgement of understanding by 11.01.12.
Program Director will conduct monthly random chart reviews to ensure compliance. Corporate Compliance Officer will conduct quarterly compliance audits.
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709.92(a) 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:
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Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan in seven of sixteen client records.
The findings include:
Sixteen client records were reviewed on October 24-25, 2012 for documentation pertaining to treatment and rehabilitation plans. The facility's policy stipulated that the individual treatment and rehabilitation plans are due within 30 days of the client's admission.
Client #3 was admitted on August 28, 2012 and the individual treatment and rehabilitation plan was to be completed by September 28, 2012. Client #3's individual treatment and rehabilitation plan was completed on October 2, 2012.
Client #9 was admitted on June 25, 2012 and discharged on August 2, 2012. The individual treatment and rehabilitation plan was to be completed by July 25, 2012. At the time of the inspection, client #9's individual treatment and rehabilitation plan was not documented for review.
Client #10 was admitted on August 10, 2012 and discharged on October 11, 2012. The individual treatment and rehabilitation plan was to be completed by September 10, 2012. At the time of the inspection, client #10's individual treatment and rehabilitation plan was not documented for review.
Client #13 was admitted on March 7, 2012 and discharged on July 2, 2012. The individual treatment and rehabilitation plan was to be completed by April 7, 2012. Client #13's individual treatment and rehabilitation plan was completed on May 4, 2012.
Client #14 was admitted on June 11, 2012 and discharged on October 3, 2012. The individual treatment and rehabilitation plan was to be completed by July 11, 2012. Client #14's individual treatment and rehabilitation plan was completed on July 14, 2012.
Client #15 was admitted on December 15, 2011 and discharged on July 5, 2012. The individual treatment and rehabilitation plan was to be completed by January 15, 2012. Client #15's individual treatment and rehabilitation plan was completed on March 2, 2012.
Client #16 was admitted on March 20, 2012 and discharged on August 1, 2012. The individual treatment and rehabilitation plan was to be completed by April 20, 2012. At the time of the inspection, client #16's individual treatment and rehabilitation plan was not documented for review.
An interview with the facility director on October 25, 2012 confirmed the findings.
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Plan of Correction
All counselors will be retrained by Corporate Compliance Officer on treatment plan writing, documentation, rehabilitation services, updates and individual specific goals by 12.21.12.
Program Director and counselors will conduct monthly random chart reviews to ensure compliance. Corporate Compliance Officer will conduct quarterly compliance audits.
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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 frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plans in four of sixteen client records.
The findings include:
Sixteen outpatient client records were reviewed on October 24-25, 2012. Sixteen client records contained individual treatment and rehabilitation plans which were required to include the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans contained in client records # 5, 6, 7 and 13 did not include the frequency of treatment and rehabilitation services
Client #5 was admitted to treatment on June 19, 2012. The individual treatment and rehabilitation plan was developed on July 5, 2012. The treatment plan did not include the type of counseling sessions or the frequency of sessions.
Client #6 was admitted to treatment on July 12, 2012. The individual treatment and rehabilitation plan was developed on August 10, 2012. Individual and group sessions were recommended, but the frequency of those sessions was not documented.
Client #7 was admitted to treatment on July 3, 2012. The individual treatment and rehabilitation plan was developed on August 3, 2012. Individual and group sessions were recommended, but the frequency of those sessions was not documented.
Client #13 was admitted to treatment on March 7, 2012. The individual treatment and rehabilitation plan was developed on May 4, 2012. Individual and group sessions were recommended, but the frequency of those sessions was not documented.
An interview with the facility director on October 25, 2012 confirmed the findings.
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Plan of Correction
All counselors will be retrained by Corporate Compliance Officer on treatment plan writing, documentation, rehabilitation services, type and frequency of treatment and rehabilitation services, updates and individual specific goals by 12.21.12.
Program Director and counselors will conduct monthly random chart reviews to ensure compliance. Corporate Compliance Officer will conduct quarterly compliance audits
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of client records, the facility failed to document support services on eleven of eleven client records reviewed.
The findings include:
Sixteen client records were reviewed on October 24-25, 2012. Eleven client records were reviewed for documentation of proposed support services on the client's treatment plan. Client records # 1, 2, 3, 4, 5, 6, 7, 8, 12, 13 and 14 had no documentation of proposed support services on the comprehensive treatment plan. An interview with the facility director on October 25, 2012 confirmed the findings.
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Plan of Correction
All counselors will be retrained by Corporate Compliance Officer on treatment plan writing, documentation, rehabilitation services, type and frequency of treatment and rehabilitation services, support services, updates and individual specific goals by 12.21.12.
Program Director reviewed with all counselors on November 1, 2012 the program's Resource book to be utilized with each client individually concerning appropriate support services to be recommended.
Program Director and counselors will conduct monthly random chart reviews to ensure compliance. Corporate Compliance Officer will conduct quarterly compliance audits
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in accordance with facility policy six of nine client records.
The findings include:
Sixteen client records were reviewed on October 24-25, 2012. Nine client records were required to have a treatment plan update. Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in client records #4, 6, 8 and 14. Client #2's treatment plan update was documented late and client #5's treatment plan update did not include documentation of the client's progression in treatment per their stated goals.
Record #2 - The client was admitted on July 25, 2012. The comprehensive treatment plan was completed on August 8, 2012. A treatment plan update was due by October 8, 2012. The treatment plan update was completed on October 23, 2012.
Record #4 - The client was admitted on July 24, 2012. The comprehensive treatment plan was completed on August 24, 2012. The treatment plan update was due by October 24, 2012, and was not completed at the time of the survey. The facility failed to document the completion of a treatment plan update as of October 25, 2012.
Record #5 - The client was admitted on June 19, 2012. The comprehensive treatment plan was completed on July 5, 2012. The treatment plan update was due by September 19, 2012. The treatment plan update was completed on September 5, 2012 and failed to document the progression of treatment per their stated goals and objectives.
Record # 6 - The client was admitted on July 12, 2012. The comprehensive treatment plan was completed on August 10, 2012. The treatment plan update was due by October 10, 2012, and was not completed and was not completed at the time of the survey. The facility failed to document the completion of a treatment plan update as of October 25, 2012.
Record #8 - The client was admitted on July 5, 2012. The comprehensive treatment plan was completed on August 5, 2012. The treatment plan update was due by October 5, 2012, and was not completed and was not completed at the time of the survey. The facility failed to document the completion of a treatment plan update as of October 25, 2012.
Record #14 - The client was admitted on June 11, 2012 and discharged October 3, 2012. The comprehensive treatment plan was completed on July 14, 2012. The treatment plan update was due by September 14, 2012, and was not completed and was not completed at the time of the survey. The facility failed to document the completion of a treatment plan update as of October 3, 2012.
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Plan of Correction
All counselors will be retrained by Corporate Compliance Officer on treatment plan writing, documentation, rehabilitation services updates and individual specific goals by 12.21.12.
Program Director provided counselors a revised monitoring grid to maintain records for all individual clients on October 31, 2012.
Program Director and counselors will conduct monthly random chart reviews to ensure compliance. Corporate Compliance Officer will conduct quarterly compliance audits
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in four of eleven client records.
The findings include:
Sixteen client records were reviewed on October 24-25, 2012. Case consultations were required in eleven of the sixteen client records, # 2, 4, 5, 6, 7, 8, 9, 13, 14, 15 and 16. The facility policy stated that case consultations are due within 90 days of the admission date. The facility did not document case consultations in client records, #4, 5, 6 and 16. An interview with the facility director on October 25, 2012 confirmed the findings.
Client # 4 was admitted on July 24, 2012. The case consultation was due October 24, 2012. No documentation of a case consultation was found in the client record.
Client # 5 was admitted on June 19, 2012. The case consultation was due September 19 2012. No documentation of a case consultation was found in the client record.
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Client # 6 was admitted on July 12, 2012. The case consultation was due October 12, 2012. No documentation of a case consultation was found in the client record.
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Client #16 March 20, 2012 and discharged on August 1, 2012. The case consultation was due June 20, 2012. No documentation of a case consultation was found in the client record.
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Plan of Correction
Program Director re- trained all counselors on Case Consultation procedures and documentation on 11/01/12.
Program Director provided counselors a revised monitoring grid to maintain records for all individual clients on October 31, 2012.
Program Director and counselors will conduct monthly random chart reviews to ensure compliance. Corporate Compliance Officer will conduct quarterly compliance audits
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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 include components in the aftercare plan.
The findings include:
Sixteen client records were reviewed on October 24-25, 2012. Two discharge client records were required to have documentation of an aftercare plan, # 9 and 13. The following components are required to be documented on the aftercare plan; goals with time frames, support services, contact person and the reentry process. The facility failed to include time frames with the goals documented on the aftercare plans for client # 9 and 13.
Client #9 was admitted on June 25, 2012 and discharged on August 2, 2012.
Client #13 was admitted on March 7, 2012 and discharged on July 2, 2012.
An interview with the facility director on October 25, 2012 confirmed the findings.
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Plan of Correction
Program Director trained all counselors on October 18, 2012 regarding Aftercare Plans and Procedures for individual clients.
Program Director re-trained all counselors on November 1, 2012 concerning proper procedures to initiate Aftercare plans on an individual basis for each client.
Program Director will review all discharged clients charts to ensure compliance.
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to include components in the discharge summary.
The findings include:
Sixteen client records were reviewed on October 24-25, 2012. Eight discharge client records were required to have documentation of a discharge summary, #9, 10, 11, 12, 13, 14, 15 and 16. The following components are required to be documented on the discharge summary; reason for treatment, services offered, respond to treatment and client status. The facility failed to include reason for treatment on the discharge summary's for clients #9, 13 and 15.
Per the facility's policy, discharge summaries are to be completed within 7 days after the clients' discharge date.
Client #10 was discharged on August 10, 2012. The discharge summary was to be completed by August 17, 2012. At the time of the inspection, October 25, 2012 the discharge summary was not documented in client #10's record.
Client #16 was discharged on March 20, 2012. The discharge summary was to be completed by March 27, 2012. At the time of the inspection, October 25, 2012 the discharge summary was completed on October 1, 2012 in client #10's record.
An interview with the facility director on August 30, 2012 confirmed the findings.
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Plan of Correction
All counselors will be provided informative packets on Discharge Summaries that will include specific requirements of a completed discharge summary. All counselors will sign acknowledgement of understanding by11.01.12.
Program Director will review all discharged clients charts within 14 days of discharge to ensure compliance.
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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 client record review, the facility failed to document a follow up attempt in seven of eight discharge client records.
The findings include:
Sixteen client records were reviewed on October 24-25, 2012. A follow up attempt is required in eight of the client records. The facility did not document a follow up in five client records, #10, 11, 15, 14 and 16. The facility policy states that follow up will be attempted within seven days for referrals and 7 days for all other discharges. An interview with the facility director on October 25, 2012 confirmed the findings.
Client #9 was discharged on August 2, 2012. The follow-up attempt was to be documented by August 9, 2012. Their follow-up attempt was documented on August 30, 2012.
Client #10 was discharged on October 11, 2012. The follow-up attempt was to be documented by October 18, 2012. There was no follow-up attempt documented in client record #10.
Client #11 was discharged on August 12, 2012. The follow-up attempt was to be documented by August 19, 2012. There was no follow-up attempt documented in client record #11.
Client #13 was discharged on July 2, 2012. The follow-up attempt was to be documented by July 9, 2012. Their follow-up attempt was documented on July 11, 2012.
Client #14 was discharged on October 3, 2012. The follow-up attempt was to be documented by October 10, 2012. There was no follow-up attempt documented in client record #14.
Client #15 was discharged on July 5, 2012. The follow-up attempt was to be documented by July 12, 2012. There was no follow-up attempt documented in client record #15.
Client #16 was discharged on August 1, 2012. The follow-up attempt was to be documented by August 8, 2012. There was no follow-up attempt documented in client record #16.
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Plan of Correction
Counselors have completed follow-up calls for Charts #10, 11, 14, 15 and 16. All follow-up calls were completed by November 9, 2012.
All counselors will be provided informative packets on Discharge Summaries that will include specific requirements of a completed discharge summary. Counselors were also re-trained on conducting the follow-up information procedure on all clients discharged from the facility. Timelines of all necessary documentation was provided.
All counselors will sign acknowledgement of understanding by 11.01.12.
Program Director will review all discharge summaries within 5 days of discharge to ensure compliance.
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