INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 30, 2012 licensure renewal inspection. The follow-up inspection was conducted on July 2, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, A Better Today, Inc. Satellite Hazleton 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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709.26(a)(10) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(10) Work performance evaluations.
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Observations
An on-site follow-up inspection was conducted on July 2, 2013. In addition, an on-site follow-up inspection was conducted at the administrative office on July 3, 2013. As a result of the follow-up inspections, it has been determined that the facility remains out of compliance with the regulation, as detailed below:Based upon the review of employee records, a review of Plans of Correction submitted by the facility for the annual licensing inspection conducted on November 30, 2012, and an interview with the Project Director, the facility failed to document an annual employee evaluation in one of one employee records.The findings include:The facility's Plans of Correction that were submitted for the annual licensing inspection conducted on November 30, 2012, specified that employee # 1 would have an annual evaluation completed in January of 2013.One employee record requiring an annual evaluation was reviewed on July 3, 2013. The annual evaluation that was to be completed in January of 2013 was not included in employee record # 1.During an interview conducted on July 3, 2013, employee # 1, the Project Director, confirmed that his annual evaluation was not completed as specified in the Plans of Correction referenced above.The original deficiency is listed below:Based upon the review of the facility's Policy & Procedure (P&P) Manual and personnel records, the facility failed to follow its own policy in regard to the completion of employee work performance evaluations.The findings include:The P&P Manual and employee records were reviewed as part of an Administrative Review which was conducted from November 19 - 20, 2012. The facility's policy titled, "A Better Today Incorporated Work Performance Evaluations," specified the following information: "All employees receive work performance evaluations. The evaluations are filled out by the employee's supervisor. The evaluations are personally shared with the employee and she/he is entitled to make comments as appropriate. Permanent employees will be evaluated on an annual basis in January of each year."Two employee records requiring documentation of employee evaluations were reviewed on November 20, 2012. One of two records, specifically # 1, contained an annual performance evaluation that was not completed as per policy.Employee # 1, the Project Director, was a permanent employee who was hired on October 1, 1987. Therefore, an annual performance evaluation was due no later than January 31, 2012. However, the record contained an evaluation that was late as it was completed and signed by the employee on October 2, 2012. In addition, the evaluation was not completed by the employee's supervisor as specified in the policy. Instead, the evaluation was completed by an employee who was supervised by the Project Director.The findings were confirmed by the Project Director during the exit interview.
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Plan of Correction
We will be revising our existing policy to show that performance evaluations will be conducted on the anniversary date of each employee's hire date.
After this review we are currently in the process of rewriting our policy and procedure manual to better outline the dates that performance reviews are due. This will be completed by December 31, 2013.
Employee #1 was hired October 1, 1987 and therefore will be due for his performance review on October 1, 2013. At that time the review will be conducted by a member of the board of directors.
In the future all employee charts will be reviewed by the office manager on a semi annual basis to verify that all documentation is complete and up to date. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
An on-site follow-up inspection was conducted on July 2, 2013. As a result of the follow-up inspection, it has been determined that the facility remains out of compliance with the regulation, as detailed below:Based upon the review of client sign-in sheets and an interview with a facility counselor, the facility failed to protect the confidentiality of client identities in three of three months reviewed.The findings include:Client sign-in sheets for group counseling sessions were reviewed on July 2, 2013. The facility failed to protect the confidentiality of client identities that were listed on client sign-in sheets during the months of March, April and May 2013.A facility counselor confirmed that the client sign-in sheets were constructed by the facility and contained the full names of clients. The counselor also confirmed that the signatures contained on the sign-in sheets were client signatures, that the sign-in sheets were accessible by all clients attending the sessions and that client confidentiality had been compromised. The original deficiency is listed below:Based upon observation of the Drug and Alcohol Licensing Specialist, the facility failed to protect the confidentiality of client identities.The findings include:Upon arriving at the facility on November 30, 2012, the Licensing Specialist observed four client sign-in sheets situated on top of a counter just inside the main door. Four of four sign-in sheets listed a minimum of 10 clients by using their first and last names. In addition, at least two clients had signed in and had access to all of the other client's names. Therefore, the facility failed to protect the identity of its clients.The findings were confirmed by the Clinical Director.
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Plan of Correction
The facility failed to protect the confidentiality of client identities that were listed on client sign-in sheets during the months of March, April and May 2013.
This problem was corrected by reformatted our sign in sheets to only include the first name of each cleint, and the first initial of their last names. All facilites have been directed that all sign in sheets must continue to be formattted in this manner.
Our quality assurance team will chack while visiting each facility to assure all sign in sheets are formatted correctly to protect the confidentiality of client identities. These measures have already been taken and will be ongoing. |
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
An on-site follow-up inspection was conducted on July 2, 2013. As a result of the follow-up inspection, it has been determined that the facility remains out of compliance with the regulation, as detailed below:Based upon the review of client records, the facility failed to document individualized treatment and rehabilitation plans in five of eight client records.The findings include:Eight client records requiring individualized treatment and rehabilitation plans were reviewed on July 2, 2013. Individualized treatment plans were not included in client records # 1, 2, 3, 7 and 8.The findings were confirmed by a facility counselor during the exit interview.The original deficiency is listed below:Based upon the review of treatment plans, the facility failed to document individualized rehabilitation and treatment plans for each client.The findings include:Seven client records requiring documentation of individualized rehabilitation and treatment plans were reviewed on November 30, 2012. The facility failed to document individualized treatment plans in three of seven records, specifically #'s 2, 4, and 7.Client # 2 was admitted on October 23, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed and dated by the client on October 23, 2012. However, the treatment plan was not individualized. Instead, the treatment plan was a standardized form that was the same as the treatment plan found in record # 4.Client # 4 was admitted on November 23, 2012, and was still an active client on the date of inspection. The record contained a treatment plan that was signed and dated by the counselor on November 30, 2012. However, the treatment plan was not individualized. Instead, the treatment plan was a standardized form that was the same as the treatment plan found in record # 2.Client # 7 was admitted on June 26, 2012, and was still an active client on the date of inspection. A treatment plan was due no later than July 6, 2012. However, the record did not include an individual treatment plan as of the date of inspection.The findings were confirmed with the Clinical Director during the exit interview.
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Plan of Correction
Eight client records requiring individualized treatment and rehabilitation plans were reviewed on July 2, 2013. Individualized treatment plans were not included in client records # 1, 2, 3, 7 and 8.
As a result we have began a staff training program to assure our clinical documentation meets the standards of A Better Today. We are now conducting ongoing trainings on our documentation policies. We are continuing to provide training and have a quality assurance team in place to find these errors and return them to the counselors so they are able to see and learn from the mistakes they are making.
As we continue to teach our incoming staff this procedure will assure that all new treatment plans are individualized to each client. We will continue to use the standardized plans that are mandatory for each client and add their individualized plans on as well. This process is currently ongoing, and will be monitored on a monthly basis during the quality assurance team's chart reviews. |
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
An on-site follow-up inspection was conducted on July 2, 2013. As a result of the follow-up inspection, it has been determined that the facility remains out of compliance with the regulation, as detailed below:Based upon the review of client records, the facility failed to include updated treatment and rehabilitation plans in six of six client records.The findings include:Six client records requiring updated treatment and rehabilitation plans were reviewed on July 2, 2013. Updated treatment and rehabilitation plans were not included in client records # 2, 3, 4, 6, 7 and 8.The findings were confirmed by a facility counselor during the exit interview.The original deficiency is listed below:Based upon the review of client records, the facility failed to document updated treatment plans that included the client's progress relative to the individual treatment plan.The findings include: Three client records requiring documentation of updated treatment plans were reviewed on November 30, 2012. Two of three records, specifically #'s 7 and 8, either did not include treatment plan updates or contained treatment plan updates that did not include the client's progress relative to their individualized treatment plan.Client # 7 was admitted on June 26, 2012 and was still an active client on the date of inspection. An individualized treatment plan was due no later than July 6, 2012, but was not included in the record. In addition, updated treatment plans documented for August 26, 2012 and November 26, 2012, were included in the record. However, both updates failed to include the client's progress relative to their individual treatment plan. Instead the updated treatment plans were standardized forms that were identical from update to update.Client # 8 was admitted on September 27, 2011, and was discharged on March 22, 2012. The record contained an individual treatment plan that was signed and dated by the client on September 27, 2011. Treatment plan updates were due on or by November 26, 2011, and January 25, 2012. However, the record did not include documentation of either update.The findings were confirmed with the Clinical Director during the record review.
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Plan of Correction
Our policy is to keep treatment plans and treatment plan updates in a separate chart until they can be reviewed by our medical director. This usually takes place on a weekly basis and the treatment plans are then filed in the clinical charts. However our medical director was on medical leave due to surgery and the treatment plans were left out of the chart pending review longer than expected. Our medical director can be contacted for confirmation if necessary.
Our medical director has since returned and all treatment plans and updates are once again being reviewed and filed on a weekly basis. All of the past treatment plans that were out of the charts have now been filed. We have spoken to the doctor about this matter and he will refer us to the doctor that covers for him when and if a similar situation ever occurs in the future. This will be an ongoing plan.
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709.93(a) 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:
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Observations
An on-site follow-up inspection was conducted on July 2, 2013. As a result of the follow-up inspection, it has been determined that the facility remains out of compliance with the regulation, as detailed below:Based upon the review of client records, the facility failed to document information relative to the client's involvement with the project in thirteen of thirteen client records.The findings include:Thirteen client records were reviewed on July 2, 2013. The facility failed to document a complete client record for clients # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13. - Individualized treatment plans were not included in client records # 1, 2, 3, 7 and 8.- Updated treatment and rehabilitation plans were not included in client records # 2, 3, 4, 6, 7 and 8.- Complete records of services provided were not included in client records # 1, 2, 3, 4, 5, 6, 7 and 8.- Case consultation notes were not included in client records # 2, 3, 4, 6, 7 and 8.- Aftercare plans were not included in client records # 9, 10, 12 and 13.- Discharge summaries were not included in client records # 10, 11, 12 and 13.The findings were confirmed by a facility counselor during the exit interview.The original deficiency is listed below:Based upon the review of client records and a conversation with the clinical director and project director, it was not possible to determine if the client records were complete or accurate.The findings include:Upon arriving at the facility on November 30, 2012, the clinical director and project director informed the Licensing Specialist that there were issues with the treatment plans and discharge summaries. The project director stated that an employee of the project independently edited and / or corrected clinical documents that they had not created. The project director stated that she then signed the documents as the clinician and dated them as though they were the originals. The project director stated that because of concerns regarding the falsification of records he had instructed the clinical director to remove all treatment plans and discharge summaries from the records.Seven client records requiring documentation of treatment plans were reviewed on November 30, 2012. One of seven records, specifically record # 7, was missing the master treatment plan. However, it was not possible to determine if the treatment plan had not been completed or if it had been removed and not returned. The remaining six client records, #'s 1, 2, 4, 5, 6 and 8 had treatment plans that were put back in the records. However, it was not possible to determine if the treatment plans were the originals or if they had been altered.Five client records requiring documentation of discharge summaries were also reviewed on November 30, 2012. Four of five records reviewed, specifically #'s 8, 9, 11 and 12 were missing discharge summaries. However, it was not possible to determine if the discharge summaries had not been completed or if they had been removed and not returned. The remaining client record, # 10, had a discharge summary that was put back in the record. However, it was not possible to determine if that discharge summary was the original or if it had been altered.The totality of the altered documents is not currently known.
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Plan of Correction
Thirteen client records were reviewed on July 2, 2013. The facility failed to document a complete client record for clients # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13.
Based on these findings we have began a staff training program to assure our clinical documentation meets the standards of A Better Today. We are now conducting ongoing trainings on our documentation policies, however with our satellite facilities and daily activities it has been a challenge to have all staff trained at once so we have been doing so on an rotating schedule which unfortunately has left some of our staff not as well trained as others.
We are continuing to provide training and have a quality assurance team in place to find these errors and return them to the counselors so they are able to see and learn from the mistakes they are making.
Ongoing in-service trainings have been schedule to review the correct way of documenting all clinical records but also to review the time frame in which this must be completed. Our quality assurance team will be making weekly trips to all facilities to assure these requirements are being met, and any staff who is not following company policy will face immediate disciplinary action.
As we continue to teach our incoming staff this procedure will assure that all new treatment plans are individualized to each client, and all other documentation is completed in a timely manner. This will be continuously monitored by the quality assurance team. This process is currently ongoing.
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709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based upon the review of client records, the facility failed to document a complete record of services provided in eight of eight client records:The findings include:Eight client records requiring a complete record of services provided were reviewed on July 2, 2013. The facility failed to document a complete record of services provided in client records # 1, 2, 3, 4, 5, 6, 7 and 8.Client # 1 was admitted on April 24, 2013, and was still an active client on the date of inspection. The record included group counseling notes for the following dates that were not included on the record of services provided: April 29 and 30, 2013; and May 6 and 8, 2013.Client # 2 was admitted on February 21, 2013, and was still an active client on the date of inspection. The record included group counseling notes for the following dates that were not included on the record of services provided: March 6, 13, 20, 25 and 27, 2013; April 1, 3, 5, 10, 15, 19, 22, 26 and 29, 2013; May 1, 3, 8, 10, 13, 15, 17, 22, 24, 29 and 31, 2013; and June 7, 2013.Client # 3 was admitted on March 15, 2013, and was still an active client on the date of inspection. The record included group counseling notes for the following dates that were not included on the record of services provided: March 25, 2013; April 5, 12 and 19, 2013; and May 10, 17 and 24, 2013.Client # 4 was admitted on February 11, 2013, and was still an active client on the date of inspection. The record included group counseling notes for the following dates that were not included on the record of services provided: March 11, 2013; April 10 and 23, 2013; May 1, 6, 8, 13, 15 and 29, 2013; and June 5, 2013.Client # 5 was admitted on May 8, 2013, and was still an active client on the date of inspection. The record included group counseling notes for the following dates that were not included on the record of services provided: May 13, 17, 20 and 31, 2013; and June 7, 10 and 17, 2013.Client # 6 was admitted on March 20, 2013, and was still an active client on the date of inspection. The record included group counseling notes for the following dates that were not included on the record of services provided: March 27 (x 2) and 28, 2013; April 24, 2013; May 1, 3, 6, 8, 15, 21, 23, 28 and 30, 2013; and June 10, 2013.Client # 7 was admitted on March 14, 2013, and was still an active client on the date of inspection. The record included group counseling notes for the following dates that were not included on the record of services provided: March 27, 2013; April 5, 8 and 26, 2013; and May 1, 10, 15, 17 and 20, 2013.Client # 8 was admitted on February 26, 2013, and was still an active client on the date of inspection. The record included group counseling notes for the following dates that were not included on the record of services provided: March 25, 27 and 28, 2013; April 8, 9, 10, 15, 16, 17, 18, 22, 23 and 30, 2013; May 2, 6, 13, 15, 20, 23, 28 and 30, 2013; and June 3 and 4, 2013.The findings were confirmed by a facility counselor during the exit interview.
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Plan of Correction
Eight client records requiring a complete record of services provided were reviewed on July 2, 2013. The facility failed to document a complete record of services provided in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
Our agency policy is to complete record of service forms when notes are filed into the charts. Counselors are required to have their notes completed within 24 hours of the service being rendered.
We now have formatted a regular schedule to ensure that the progress notes are filed then the record of service forms are completed within a timely manner. This is completed on an ongoing basis, and will be monitored by our quality assurance team to verify procedures are being followed. |
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 upon the review of client records, the facility failed to document case consultation notes in six of six client records.The findings include:Six client records requiring case consultation notes were reviewed on July 2, 2013. Case consultation notes were not included in client records # 2, 3, 4, 6, 7 and 8.Client # 2 was admitted on February 21, 2013, and was still an active client on the date of inspection. A case consultation note was due no later than May 22, 2013; however, as of the date of inspection, the record did not include any case consultation notes.Client # 3 was admitted on March 15, 2013, and was still an active client on the date of inspection. A case consultation note was due no later than June 13, 2013; however, as of the date of inspection, the record did not include any case consultation notes.Client # 4 was admitted on February 11, 2013, and was still an active client on the date of inspection. A case consultation note was due no later than June 12, 2013; however, as of the date of inspection, the record did not include any case consultation notes.Client #6 was admitted on March 20, 2013, and was still an active client on the date of inspection. A case consultation note was due no later than June 18, 2013; however, as of the date of inspection, the record did not include any case consultation notes.Client # 7 was admitted on March 14, 2013, and was still an active client on the date of inspection. A case consultation note was due no later than June 12, 2013; however, as of the date of inspection, the record did not include any case consultation notes.Client # 8 was admitted on February 26, 2013, and was still an active client on the date of inspection. A case consultation note was due no later than May 27, 2013; however, as of the date of inspection, the record did not include any case consultation notes.The findings were confirmed by a counselor during the exit interview.
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Plan of Correction
Six client records requiring case consultation notes were reviewed on July 2, 2013. Case consultation notes were not included in client records # 2, 3, 4, 6, 7 and 8.
Based on this review we have began staff training to assure all clinical charts meet the standards set by A Better Today.
Our policy is to keep case consultations in a separate chart until they can be reviewed by the clinical supervisor. This takes place on a weekly basis and the treatment plans are then filed in the clinical charts.
The case consultations that were missing from the charts were in a separate file for review, and have since been filed into the charts.
We now have formatted a regular schedule to assure that the case consultations are filed in a timely manner. This will be monitored by our quality assurance team on an ongoing basis.
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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
An on-site follow-up inspection was conducted on July 2, 2013. As a result of the follow-up inspection, it has been determined that the facility remains out of compliance with the regulation, as detailed below:Based upon the review of client records, the facility failed to document aftercare plans in four of five discharged client records.The findings include:Five discharged client records requiring aftercare plans were reviewed on July 2, 2013. Aftercare plans were not included in client records # 9, 10, 12 and 13 as of the date of inspection.The findings were confirmed by a facility counselor during the exit interview.The original deficiency is listed below:Based upon the review of client records, the facility failed to document aftercare plans for clients who were successfully discharged from the program.The findings include:Four client records requiring documentation of an aftercare plan were reviewed on November 30, 2012. Two of four records, specifically #'s 8 and 9, did not include client aftercare plans.Client # 8 was admitted on September 27, 2011, and was successfully discharged on March 22, 2012. Therefore, an aftercare plan was due no later than March 22, 2012. However, as of the date of inspection, the record did not include an aftercare plan.Client # 9 was admitted on May 29, 2012, and was successfully discharged on October 11, 2012. Therefore, an aftercare plan was due no later than October 11, 2012. However, as of the date of inspection, the record did not include an aftercare plan.The findings were confirmed by the Clinical Director during the record review.
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Plan of Correction
Five discharged client records requiring aftercare plans were reviewed on July 2, 2013. Aftercare plans were not included in client records # 9, 10, 12 and 13 as of the date of inspection.
Based on these findings we have began a staff training program to assure our clinical documentation meets the standards of A Better Today. We are now conducting ongoing trainings on our documentation policies. We are continuing to provide training and have a quality assurance team in place to find these errors and return them to the counselors so they are able to see and learn from the mistakes they are making.
In this training all pertinent clinical documentation including but not limited to master treatment plans, Treatment plan updates, progress notes, case consultations, after care plans, and discharge summaries were reformatted and redeveloped. Training on all clinical documentation will continuously occur on a weekly basis and will be overseen by the clinical director. Quality assurance will also be conducted on an monthly basis by our quality assurance team to assure the proper procedures continue to be followed. This will be ongoing.
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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
An on-site follow-up inspection was conducted on July 2, 2013. As a result of the follow-up inspection, it has been determined that the facility remains out of compliance with the regulation, as detailed below:Based upon the review of client records, the facility failed to document discharge summaries in four of five discharged client records.The findings include:Five discharged client records requiring discharge summaries were reviewed on July 2, 2013. Discharge summaries were not included in client records # 10, 11, 12 and 13.Client # 10 was admitted on January 8, 2013, and was discharged on June 7, 2013. A discharge summary was to be completed no later than June 14, 2013; however, as of the date of inspection, the record did not include a discharge summary.Client # 11 was admitted on April, 2, 2013, and was discharged on June 21, 2013. A discharge summary was to be completed no later than June 28, 2013; however, as of the date of inspection, the record did not include a discharge summary.Client # 12 was admitted on April, 26, 2013, and was discharged on June 13, 2013. A discharge summary was to be completed no later than June 20, 2013; however, as of the date of inspection, the record did not include a discharge summary.Client # 13 was admitted on December, 28, 2012, and was discharged on May 28, 2013. A discharge summary was to be completed no later than June 4, 2013; however, as of the date of inspection, the record did not include a discharge summary.The findings were confirmed by a facility counselor during the exit interview.The original deficiency is listed below:Based upon the review of client records, the facility failed to document discharge summaries.The findings include:Five client records requiring documentation of discharge summaries were reviewed on November 30, 2012. Four of five records, specifically #'s 8, 9, 11 and 12, did not include discharge summaries.Client # 8 was admitted on September 27, 2011, and was discharged on March 22, 2012. Therefore, a discharge summary was due no later than March 29, 2012. However, the record did not include a discharge summary as of the date of inspection.Client # 9 was admitted on October 17, 2011, and was discharged on January 29, 2012. Therefore, a discharge summary was due no later than February 5, 2012. However, the record did not include a discharge summary as of the date of inspection.Client # 11 was admitted on August 27, 2012, and was discharged on September 25, 2012. Therefore, a discharge summary was due no later than October 2, 2012. However, the record did not include a discharge summary as of the date of inspection.Client # 12 was admitted on May 29, 2012, and was discharged on October 11, 2012. Therefore, a discharge summary was due no later than October 18, 2012. However, the record did not include a discharge summary as of the date of inspection.The findings were confirmed by the Clinical Director during the record review.
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Plan of Correction
Five discharged client records requiring discharge summaries were reviewed on July 2, 2013. Discharge summaries were not included in client records # 10, 11, 12 and 13.
Based on these findings we have began a staff training program to assure our clinical documentation meets the standards of A Better Today. We are now conducting ongoing trainings on our documentation policies. We are continuing to provide training and have a quality assurance team in place to find these errors and return them to the counselors so they are able to see and learn from the mistakes they are making.
In this training all pertinent clinical documentation including but not limited to master treatment plans, Treatment plan updates, progress notes, case consultations, after care plans, and discharge summaries were reformatted and redeveloped. Training on all clinical documentation will continuously occur on a weekly basis and will be overseen by the clinical director. Quality assurance will also be conducted on a monthly basis by the quality assurance team to assure the proper procedures continue to be followed. This is ongoing. |