INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 1 - 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. - Allentown 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records, the facility failed to ensure clinical supervisor completed a core curriculum in clinical supervision within a timely fashion.
Employee #3 was promoted to a clinical supervisor position on October 24, 2019 and was still in that position at the time of the inspection. Employee did not complete the core curriculum training until October 15, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Current clinical supervisor took this assignment August 2, 2020, not October 24, 2019. Clinical Supervisor training was completed in October 2021. Due to Covid 19 the lack of availability of training delayed the completion.
Clinic director will have oversight and monitor due dates for necessary trainings to ensure compliance with DDAP regulations for the position of Clinical Supervisor. |
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 form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a counselor on July 6, 2021 and was due to have the communicable disease trainings no later than July 6, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #6 completed TB/STD/Hep December 7, 2021 and is scheduled to complete HIV in 2022. As of 01/01/2022, all newly hired staff will complete HIV/AIDS and TB/STD training within the first year of hire, in accordance with the State regulation. The Clinical Supervisor will monitor all training requirements on a quarterly basis and report updates to the CTC Director via a quarterly training report.
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709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of patient records, the facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed and keep disclosure of client identifying information within the limited established by 4 Pa. Code 255.5(b) in two out of eight records reviewed.
Patient #1 was admitted on September 1, 2021 and was still active at the time of the inspection. A release of information dated May 6, 2021 to an attorney listed the information to be disclosed as "in treatment letter". An additional release dated May 6, 2021 to a government agency listed information to be released as "promise".
Patient #4 was admitted on May 30, 2017 and was still active at the time of the inspection. A release of information dated May 21, 2021 to a funding source permitted "services provided daily" which is outside the scope of 4 Pa. Code 255.5(b).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with confidentiality. The CTC Director & Clinical Supervisor, as well as the RD, will re-review the requirements for release of information and confidentiality documentation with all counselors on 1/3/2022 during our monthly team meeting. Clinic Director and Clinical Supervisor will ensure that all release of information forms will indicate a specific purpose of the disclosure to named parties within the ROI. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of patient records, the facility failed to obtain a completed informed and voluntary consent which included purpose of disclosure in two out of eight records reviewed.
Patient #1 was admitted on September 1, 2021 and was still active at the time of the inspection. A consent to release form dated May 6, 2021 listed purpose of disclosure as "in treatment letter". A second release dated May 6, 2021 to a government agency listed purpose of disclosure as "promise".
Patient #2 was admitted on April 26, 2021 and was still active at the time of the inspection. A consent to release form dated April 26, 2021 listed purpose of disclosure as "n/a".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with confidentiality. The CTC Director & Clinical Supervisor, as well as the RD, will re-review the requirements for release of information and confidentiality documentation with all counselors on 1/3/2022 during our monthly team meeting. Clinic Director and Clinic Director will ensure that all release of information forms will indicate a specific purpose of the disclosure to named parties within the ROI. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. |
709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of patient records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of patient in three out of eight records reviewed.
Patient # 4 was admitted on May 30, 2017 and was still active at that the time of the inspection. One release of information dated May 25, 2021 was to a funding source. An additional release of information dated May 25, 2021 was to an emergency contact.
Patient #5 was admitted on August 27, 2019 and was still active at the time of the inspection. A release of information form dated March 25, 2021 was to a funding source.
Patient #8 was admitted on September 11, 2017 and discharged on October 1, 2021. A release of information dated February 4, 2021 was to an emergency contact.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with confidentiality. The CTC Director & Clinical Supervisor, as well as the RD, will re-review the requirements for release of information and confidentiality documentation with all counselors on 1/3/2022 during our monthly team meeting. Clinic Director and Clinical Supervisor will ensure that all release of information forms will include a dated signature of the patient. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. |
709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of patient records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of a witness in one out of eight records reviewed.
Patient # 4 was admitted on May 30, 2017 and was still active at that the time of the inspection. One release of information dated May 25, 2021 was to a funding source.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with confidentiality. The CTC Director & Clinical Supervisor, as well as the RD, will re-review the requirements for release of information and confidentiality documentation with all counselors on 1/3/2022 during our monthly team meeting. Clinic Director and Clinical Supervisor will ensure that all release of information forms will include a dated witness signature. All releases of information will be reviewed for accuracy and that these releases of information are completed in its entirety on a monthly basis. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of physician timesheets for the months of July, August and September 2021, the facility failed to provide at least one hour of physician time a week, onsite for every ten patients.
During the week of August 22-28, 2021, the patient census was 322. The facility was required to provide at least 32.2 physician hours. There were 14 physician hours documented, which were all provided by a medical doctor.
During the week of August 29-September 4, 2021, the patient census was 324. The facility was required to provide at least 32.4 physician hours. There were 23 physician hours document, which were all provided by the certified registered nurse practitioner.
During the week of September 26-October 2, 2021, the patient census was 330. The facility was required to provide at least 33 physician hours. There were 29.5 physician hour document, nine of which were provided by a medical doctor and 20.5 provided by the certified registered nurse practitioner.
This is a repeat citation from the January 6, 2021, November 22, 2019, December 6, 2018, November 28, 2017 and October 19, 2016 licensing inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director will ensure that the Program Physician(s) provide at least 1 hour per week onsite for every ten patients. A Physician schedule has been developed as of 1/01/2022 and will be submitted to the medical staff monthly to ensure there is adequate coverage. The CTC Director will monitor the monthly calendar to ensure there is adequate coverage.
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715.8(1)(vi) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 35/1.
The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE.
Employee #4 was hired as a counselor on June 30, 2020 and was still acting in that position. Employee #4 was reported to have 37.5 hours per week devoted to their 43 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 37.5/37.5 = 1 (FTE); 43/1 = 43, which equals to a client counselor ratio of 43:1.
Employee #5 was promoted to a counselor on October 24, 2019 and was still acting in that position. Employee #4 was reported to have 36.5 hours per week devoted to their 42 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 36.5/37.5 = .97 (FTE); 42/.97 = 43.2, which equals to a client counselor ratio of 43:1.
Employee #7 was hired as a counselor on September 28, 2020 and was still acting in that position. Employee #4 was reported to have 37.5 hours per week devoted to their 43 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 37.5/37.5 = 1 (FTE); 43/1 = 43, which equals a client counselor ratio of 43:1.
Employee #8 was hired as a counselor on November 23, 2020 and was still acting in that position. Employee #8 was reported to have 37.5 hours per week devoted to their 45 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 37.5/37.5 = 1 (FTE); 45/1 = 45, which equals a client counselor ratio of 45:1.
Employee #9 was hired as a counselor on July 12, 2021 and was still acting in that position. Employee #8 was reported to have 35.5 hours per week devoted to their 39 clients on their caseload.
The FTE counselor's caseload calculation is as follows: 35.5/37.5 = .94 (FTE); 39/.94 = 41.1, which equals a client counselor ratio of 41:1.
This is a repeat citation from the January 6, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In concert with 704.12 additional staffing pattern adjustments have been identified and will take effect on January 1, 2022. A reassignment of caseloads will occur, once this new staff member is on site, which will more accurately reflect regulation expectations for all clinical personnel. The Clinical Supervisor will review ratios weekly when assigning new admissions to counselors. The Clinic Director will review on a monthly or as needed basis to ensure compliance is maintained. Additionally, a thorough review of the existing staffing patterns that are in place at HOI Allentown CTC will be conducted by the Regional Director and the Clinic Director. Based on the current census and those who meet the criteria of licensing alert 01-14, the facility will meet the 35:1 requirement. Based on the current census and those who meet the criteria of licensure alert 01-14, the facility will meet the 35:1 requirement. The Clinical Supervisor will monitor ratio weekly, when assigning new admissions to counselors. The CTC Director will monitor census weekly to ensure compliance with this regulation and hire additional staff as needed. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on the observation of medication administration, the facility failed to properly verify the correct identity of a patient prior to administration of an agent. Section 6.1.1, #7d of the facility's policy and procedures manual sates "patients will present at the dispensing window without hats or sunglasses. There were five observed occurrences where the patient was not asked to remove their hat prior to dosing.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Nursing supervisor will review policy with staff. New staff will be trained on proper policy and reviewed in team meetings and supervision. The charge nurse did present this information during the monthly nursing meeting on December 13, 2021.Clinic Director will observe dosing monthly. Ongoing non compliance will be addressed by the Nurse Manager and Clinic Director individually utilizing the Employee Improvement Plan process.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician within the regulatory timeframe in two out of three applicable patient records.
Patient #5 was admitted on August 27, 2019 and was still active at the time of the inspection. An annual physical was due on August 27, 2021; however, it was not completed until September 17, 2021.
Patient #8 was admitted on September 11, 2017 and discharged on October 1, 2021. An annual physical examination was due on September 11, 2021; however, there was no documentation in the patient's record of it being completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Nursing Supervisor will pull the services due report in the EHR for the upcoming month and schedule annual physicals with the physicians. CTC director will also monitor compliance weekly and address non-compliance with the Physician as needed. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in one out of three applicable patient records reviewed.
Patient # 8 was admitted on September 11, 2017 and discharged on October 1, 2021. An annual clinical evaluation was due on September 11, 2021; however, there was no documentation in the patient's record of it being completed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services with all counselors on 1/10/2022. Immediately following this meeting, each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor weekly. Additionally the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Ongoing non compliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process.
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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 a review of patient records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of four applicable records reviewed. Section 7.1.4 of the facility's policy and procedures manual sates the comprehensive treatment plan must be completed between days 8-30 following admission.
Patient #1 was admitted on September 1, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than October 1, 2021; however, there was no documentation of it being completed at the time of the inspection.
Patient #6 was admitted on June 7, 2021 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than July 7, 2021; however, it was not completed until July 15, 2021.
Patient #7 was admitted on April 22, 2021 and discharged on June 11, 2021. A comprehensive treatment plan was due no later than May 22, 2021; however, it was not completed until June 2, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services with all counselors on 1/10/2022. immediately following this meeting, each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor weekly. Additionally the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Ongoing non compliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
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 patient records, the facility failed to document proposed type of support services in the individual treatment plan in one out of three applicable records.
Patient #7 was admitted on April 22, 201 and discharged on June 11, 2021. The comprehensive treatment plan dated June 2, 2021 did not list support services.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for treatment plans and the inclusion of support services, as identified with patient, in treatment plans, with all counselors on 1/10/2022. In supervision and when treatment plans are due, the Clinical Supervisor will review and address concerns that persist. Ongoing non compliance in including support services in treatment plans will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
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 patient records, the facility failed to update the patient's treatment and rehabilitation plans at least every 60 days in two out of five applicable records.
Patient # 2 was admitted on April 26, 2021 and was still active at the time of the inspection. A treatment plan update was completed on August 26, 2021 with the next one due by October 26, 2021; however, there was no documentation of an update at the time of the inspection.
Patient #6 was admitted on June 7, 2021 and was still active at the time of the inspection. A treatment plan update was completed on August 12, 2021 with the next one due by October 12, 2021; however, there was no documentation of an update at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services with all counselors on 1/10/2022. Immediately following this meeting, each counselor will run their Direct Services Analysis reports in SMART and turn into the Clinical Supervisor weekly. Additionally the Clinical Supervisor will run the report monthly and send results to the CTC Director and the Director of Quality and Compliance with a plan of action for overall results below the benchmark of 96%. The Clinical Supervisor will review the reports in individual and group supervision. Ongoing non compliance in meeting the Direct Services requirement will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of patient records, the facility failed to ensure that the patients received counseling services according to their individual treatment plan in four out of seven applicable records reviewed.
Patient #2 was admitted on April 26, 2021 and was still active at the time of the inspection. Treatment plans dated June 30, 2021 and August 26, 2021 indicated weekly group and individual counseling sessions. The record of service and progress notes indicated there were no individual counseling sessions between August 11-23, 2021, August 25 - September 7 (counselor cancelled on September 7, 2021) and no sessions after September 29, 2021. In addition, there was no documentation of group sessions between August 11-September 29 and October 1-15, 2021.
Patient #4 was admitted on May 30, 2017 and was still active at the time of the inspection. Treatment plans dated July 30, 2021 and September 30, 2021 indicated weekly individual sessions. The record of service and progress notes indicated there were no individual counseling sessions between August 6-19, 2021 and none after August 20, 2021.
Patient #5 was admitted on August 27, 2019 and was still active at the time of the inspection. Treatment plans dated August 27, 2021 and October 21, 2021 indicated weekly individual and group sessions. The record of service and progress notes indicated no group sessions between August 14 - 26, 2021.
Patient #6 was admitted on June 7, 2021 and was still active at the time of the inspection. Treatment plans dated July 15, 2021 and August 12, 2021 indicated weekly individual and group sessions. The record of service and progress notes indicated no group sessions between September 18-October 14, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CTC Director and Clinical Supervisor are responsible for ensuring compliance with psychotherapy services. The CTC Director & Clinical Supervisor will re-review the requirements for counseling services with all counselors on 1/10/2022. In supervision and when treatment plans are due, the Clinical Supervisor will review and address concerns that persist. Ongoing non compliance in individualizing type and frequency of counseling services will be addressed by the Clinical Supervisor individually utilizing the Employee Improvement Plan process. |
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 on review of Staffing Requirements Facility Summary Report and physician timesheets, the facility failed to comply with two plans of correction approved by the Department, resulting in repeat citations. A plan of correction was submitted to the Department for an inspection occurring on January 6, 2021, addressing the requirement to keep client/staff ratios for outpatient clients at or below the ratio of 35:1. In addition, plans of correction were submitted for inspections occurring on January 6, 2021, November 22, 2019, December 6, 2018, November 28, 2017, and October 19, 2016, addressing the requirement to provide physician services at least one hour per week onsite for every ten patients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Allentown CTC will identify issues with proposed plans of correction as they present and formulate protocols to ensure that repeat citations are avoided in the future. The current plans of correction for this audit period are believed to be attained and maintained with current staffing and policies in place. Physician Ratio: An increase in physician hours has occurred at the time of this plan of correction and adding an additional physician has been proposed to meet the physician ratio requirement. In concert with 704.12 additional staffing pattern adjustments have been identified and will take effect on January 1, 2022. A reassignment of caseloads will occur, once this new staff member is on site, which will more accurately reflect regulation expectations for all clinical personnel. The Clinical Supervisor will review ratios weekly when assigning new admissions to counselors. The Clinic Director will review on a monthly or as needed basis to ensure compliance is maintained. Additionally, a thorough review of the existing staffing patterns that are in place at Allentown CTC will be conducted by the Regional Director and the Clinic Director. Based on the current census and those who meet the criteria of licensing alert 01-14, the facility will meet the 35:1 requirement. Based on the current census and those who meet the criteria of licensure alert 01-14, the facility will meet the 35:1 requirement. The Clinical Supervisor will monitor ratio weekly, when assigning new admissions to counselors. The CTC Director will monitor census weekly to ensure compliance with this regulation and hire additional staff as needed. |