INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on June 13-15, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium, was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of employee files conducted on June 13, 2018, the facility failed to document that all staff members received an individual training plan for the training year January 1, 2018 through December 31, 2018.
Employee #5 was hired as a counselor on 10/10/2017
Employee #6 was hired as a counselor on 11/21/2017
Employee #17 was hired as a clinical supervisor on 4/18/16
Employee #18 was hired as a counselor on 7/16/2017
Employee #20 was hired as the Business Office Manager 9/24/2012
Employee #21 was hired as a the Medical Director on 7/6/1995
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 7/13/18, all managers attached to the Addictions Division will complete the Annual Employee Development Plans, with their direct reports, in conjunction with the Annual Performance Appraisals and submit them to the Assistant Division Director no later than the end of the first week in December of each year. The Assistant Division Director will implement a tracking system to verify that all plans are submitted. The Assistant Division Director will make copies and forward the original plans to the Human Resources Director no later than 12/31.
Employees #5,6,17,18,20,21, will all have their Annual Training Plans completed by 8/31/18. |
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 employee files conducted on June 13, 2018, the facility failed to document that all staff members completed the communicable disease trainings within the required timeframe.
Employee #4 was hired as a clinical supervisor on 3/27/17. The HIV/AIDS and TB/STD trainings were due to be completed by 3/27/18 but were not documented at the time of the inspection.
Employee #13 was hired as a counselor on 6/13/16. The HIV/AIDS and TB/STD trainings were due to be completed by 6/13/17 but were not documented at the time of the inspection.
Employee #19 was hired as a security staff on 4/25/16. The HIV/AIDS and TB/STD trainings were due to be completed by 4/25/18 but were not documented at the time of the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 7/23/18, supervisors will schedule their new employees for the communicable disease trainings at BHTN within 60 days of hire. This activity will be formally tracked and documented by the assistant division director, reported to the division director and forwarded to the Human Resources Department monthly. Additionally, Employee #13 will receive the required Communicable Disease Trainings at BHTN by September 28, 2018. Employees #4 and #19 are no longer with the company. |
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 employee files conducted on June 13, 2018, the facility failed to document that all staff members completed the required number of training hours.
Employee #1 was hired as the Projected Director on December 3, 2001. Training certificates were reviewed for the period from January 1, 2017 through December 31, 2017; Employee #1 had documented only 3.5 hours of trainings at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
All employees will complete the required trainings. An Excel tracking system is currently being developed to manage all staff trainings from New Hire through Annual Requirements. This includes internal trainings, external trainings, DDAP Required Trainings as well as trainings required for staff who hold Licenses. The Division Director's designee will be responsible for maintaining the tracker, alerting the staff of upcoming trainings, assisting with registrations, scanning certifications and evaluation forms and forwarding documents to Human Resources for employee files.
The Project Director will meet the required training hours for his position. The Director of Training and Licensing in conjunction with the Assistant to the Project Director will ensure that all training and webinars attended by the Project Director are documented and filed in his employee file. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of employee files conducted on June 13, 2018, the facility failed to document that all staff members completed the required number of training hours for the training year from January 1, 2017 through December 31, 2017.
Employee #9 was hired as a counselor on 10/28/2002; 21 hours of training were documented at the time of the inspection.
Employee #10 was hired as a counselor on 10/1/2012: 12 hours of training were documented at the time of the inspection.
Employee #12 was hired as a counselor on 8/22/2011; 13.5 hours of training were documented at the time of the inspection.
Employee #16 was hired as a counselor on 10/24/2011; 5.5 hours of training were documented at the time of the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 8/24/18, the Division of Addictions will implement mandatory on-site trainings on the fourth Friday of each month. The assistant division director will be responsible for tracking and documenting the training attendance of all Addictions Division staff and reporting this information to the division director as well as forwarding the sign in and evaluation forms to Human Resources. Additionally, when staff attends external trainings, they will be required to submit the original certificate to the assistant division director to place in tracker, document as viewed original and forward a copy to Human Resources. The division director will review this information with the assistant division director monthly. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of employee files conducted on June 13, 2018, the facility failed to ensure that each employee was trained to perform assigned duties during emergencies.
Employee #7 was hired as a counselor on 3/6/2018. At the time of the inspection there was no documentation that the employee was trained for emergencies.
Employee #8 was hired as a counselor on 4/16/2018. At the time of the inspection there was no documentation that the employee was trained for emergencies.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 7/23/18, The Addictions Division will ensure that employees on all shifts are trained to perform assigned tasks during emergencies and that the documentation is evident in the employee files. The Fire Safety Emergency Procedures are documented on the On-Site Orientation Competency Checklist, under the Facility Procedures, and placed in the employee's files. The immediate supervisor of each new hire is responsible for facilitating and documenting the completion of this training. Signatures, initials and dates are required by both supervisor and employee. Additionally, each manager will be required to forward the completed On-Site Competency Check List to the assistant division director to be verified for completion, placed in the tracker and forwarded to the Human Services Department for the employee's files.
Employee #8 does have the documentation in her employee file. The document is available upon request. Employee #7 does not have this document in her employee file. The training and documentation for Employee #7 will be completed by her immediate supervisor by 7/31/18.
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705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on a physical plant inspection, conducted on June 13, 2018, the facility failed to maintain protective caps over each electrical outlet.
The power strip in the children ' s activity area had four uncovered outlets.
Additionally, the wall outlet in the large activity room on the main floor did not have outlet covers.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 7/9/18: The Facilities Manager arranged for the wall outlets in the Lobby area to be capped off. They can no longer be used. The only remaining outlets are purposed for the television and the vending machines. The security and management staff will make periodic checks to ensure that that these outlets remain covered. Additionally, program managers will make periodic checks to ensure that these outlets remain covered. The Security Manager and Division Director will be responsible to ensure this task is being followed.
Effective 6/15/18:The missing outlet covers in the Child Play Room were replaced. By 8/10/18, the Facilities manager will replace the plastic outlet covers with medical Grade Power Strip Safety Outlet Covers which are the type that cannot be removed. The Facilities Director and the Division Director will be responsible to ensure completion of this task. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection, conducted on June 13, 2018, the facility failed to secure hard copy client records in locked containers.
There were active client roster lists visible on the desks in counseling offices #114, 124, 213 and 214. There were boxes of discharged client records under a chair in case manager office 227. Additionally, client records were stacked on top of file cabinets in a room that was also being used to store extra chairs and was accessible to facility maintenance staff.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 7/24/18: All staff will be required to keep all client identifying information stored securely. All clinical managers will be required to make daily spot checks to ensure adherence to this requirement.
Effective 7/24/18: All staff will be required to keep the client files that were pulled for discharging and various assignments on any given day in a locked drawer or locked cart in their offices. Clinical Managers will be required to make daily spot checks to ensure adherence to this requirement.
Effective 6/16/18: Immediately following the observation, the stacks of chairs identified were removed form the Medical Records Archive Room and stored elsewhere in the building. The key to the Medical Records Archive room are removed from the Maintenance Department key ring. Currently, the only staff with access to the Medical Records Archive Room are the Medical Records Staff and Supervisor. The Medical Records Supervisor will escort Maintenance Department Staff in that room if the need for maintenance support should arise. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Fourteen client records were reviewed on June 14-15, 2018; the facility failed to obtain a valid consent to release information in three of fourteen client records.
Client #6 was admitted on 4/6/05 and was an active client at the time of the licensing inspection.
A consent to release information to a lab was signed and dated on 4/25/17; this consent expired on 4/25/18 and a new consent was not documented in the record; a specimen was submitted to the lab on 5/16/18.
Client #7 was admitted on 2/12/10 and was an active client at the time of the licensing inspection. A consent to release information to the funding source was signed and dated on 3/1/17; this consent expired on 3/1/18 and a new consent was not documented in the record; additionally, there was no consent to release information to a lab, however specimens were sent to this lab on 3/16/18, 4/6/18, 5/4/18 and 5/25/18.
Client #13 was admitted on 12/19/17 and discharged on 5/25/18. There was no consent to release information to the funding source found in the record.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 8/1/18: The Intake Supervisor will be responsible to utilize the Intake Check List to ensure that all required intake documents and consents are completed by the client and. The Intake Check List will be included in the clients chart and signed off on by the Intake Supervisor.
Clinical Supervisors will be responsible to ensure that all updated consents are submitted annually with each client's Annual Evaluation Packet. Clinical Supervisors will document receipt of consents in the tracker. Clinical Supervisors will document lack of receipt of this information on a supervision note and place a message in AMS for the client to meet with their counselor of record to complete the assignment.
The Clinical Supervisors will review these requirements during team supervision and during individual supervision with their counselors.
The Clinical Director will review these requirements during team supervision and during individual supervision with the clinical supervisors.
Client #13 was Discharged on 5/25/18 however; the patient records for client #6 and client #7 will be made whole by 7/31/18. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
During the observation of methadone dispensing, conducted on June 14, 2018, the facility failed to maintain confidentiality of client records.
Upon arrival at the dispensing window the clients were being asked to sign in on a sheet of paper that also contained the signatures of the previous clients that had been dosed earlier at that window; some of these ' signatures ' were identifiable with first and last name.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 6/14/18: When patients present to the dispensing window they are now signing on mailing labels, one at a time. The label is then removed by the dispensing nurse and placed on a sheet of paper on the nurse's side of the dispensing room. This eliminates the patient from seeing the names of previous patients who have already been medicated for the day. The Nurse Manager is responsible to ensure that this task is followed throughout the day. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Fourteen client records were reviewed on June 14-15, 2018; the facility failed to document a personal history for client #13.
Client #13 was re-admitted on 12/19/17 and discharged on 5/25/18. The Personal history was not updated upon readmission.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 8/1/18: Within the first week of Re-Admit to treatment, the clinical supervisor will be responsible to ensure that the client meets with a clinician to review and update their file to obtain and review their file to update the client's personal history and to make any other relevant updates necessary to effectively reengage the client back into treatment. This task will be monitored via periodic chart audits and clinical supervision. |
715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
Fourteen client records were reviewed on June 14-15, 2018; the facility failed to document a complete drug and alcohol history for client #13.
Client #13 was re-admitted on 12/19/17 and discharged on 5/25/18. The drug and alcohol history was not updated upon readmission.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 8/1/18: Clinicians will document a complete drug and alcohol history for each client within 30 days of their admissions date. If the client is a re-admit, and the re-admit date is 6 months or more past the client's first admissions date, a new complete drug and alcohol history will be documented for that client. If the client's re-admissions date is less than 6 months from the original admissions date, the original drug and alcohol history will be reviewed by the client and clinician. Both will initial and date the bottom of each page and will also initial and date any updates made to the document. The clinical supervisor will be responsible to monitor and document this assignment via periodic chart reviews and supervision.
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715.23(b)(3) LICENSURE Patient records
(b) Each patient file shall include the following information:
(3) A complete medical history
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Observations
Fourteen client records were reviewed on June 14-15, 2018; the facility failed to document a medical history for client #13.
Client #13 was re-admitted on 12/19/17 and discharged on 5/25/18. The medical history was not updated upon readmission.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 8/1/18: Within the first week of Re-Admissions to treatment, the clinical supervisor will be responsible to ensure that the client meets with a clinician to review their file to update the client's medical history and to make any other relevant updates necessary to effectively reengage the client back into treatment. This task will be monitored via periodic chart reviews and clinical supervision. |
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
Fourteen client records were reviewed on June 14-15, 2018; the facility failed to document an annual physical examination for client #14.
Client #14 was re-admitted on 12/8/14 and discharged on 1/16/18.
An annual physical examination was documented on 12/8/16; another annual physical was due to be completed by 12/8/17 but was not documented at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 8/1/2018 The Nursing Manager will continue to ensure that Annual Physical appointments are scheduled and presented to the patients a month prior to their Annual Admit Date. This appointment will be documented in the AMS system where it will be accessible to for clinical staff to remind the patients when they present for individual sessions during the month prior to their Annual Physical Appointment.
Client #14. AMS Documentation shows that the patient was informed of the Annual Physical Appointment more than once. The AMS system also shows that the member was inconsistent with treatment and that the clinical team was assisting the member with entering inpatient treatment. A last Dose verification was sent to Kirkbride Center on 12-4-17. Apparently, when the member left the Kirkbride Center he did not return to the Consortium which prompted the discharge on 1/16/18.
Effective 9/1/18: With a Consent from the member, the Consortium Case Manager will facilitate at least one (1) continuity of care call each month to the documented hospital, to ascertain the status of our member. The clinical supervisor of record will be responsible for tracking this assignment and ensuring that the documentation is forwarded to the member's treatment record. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Fourteen client records were reviewed on June 14-15, 2018; the facility failed to document a biopsychosocial evaluation clinical summary for clients #5, 8, 10 & 13.
Client #5 was admitted on 10/10/17 and was an active client at the time of the licensing inspection.
Client #8 was admitted on 12/19/17 and was an active client at the time of the licensing inspection.
Client #10 was admitted on 2/1/18 and discharged on 6/6/18.
Client #13 was re-admitted on 12/19/17 and discharged on 5/25/18.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 8/1/20/18: Each biopsychosocial will include a corresponding clinical summary. The clinical supervisors will be responsible for ensuring that this assignment is completed when the bio is submitted by the clinicians. The clinical supervisors will review the entire packet, sign and verify by documenting completion in the tracker.
The Clinical Summaries for client #5 and #8 will be completed by 8/24/18. The Clinical Manager will be responsible to ensure that this assignment is completed. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Fourteen client records were reviewed on June 14-15, 2018; the facility failed to document follow up attempt for client #11.
Client #11 was admitted on 3/8/04 and discharged on 11/3/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 8/1/18: The Clinical Supervisor of record will ensure that the Peer Specialist and Case Manager complete and mail a Follow Up Letter within 30 Days of a member's Discharge Date. A copy of the 30 Day Follow Up Letter will be forwarded to the medical records department by the clinical supervisor. The medical records clerk will attach the 30 Day Follow Up Letter to the Discharged Chart. The Clinical Manager will be responsible to review this information during the discharge chart audit process. |
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
Fourteen client records were reviewed on June 14-15, 2018; the facility failed to document the annual clinical evaluation in records #4, 6, 11, 12 & 14.
Client #4 was admitted on 2/26/10 and was an active client at the time of the licensing inspection. An annual clinical evaluation was documented on 2/5/17; another annual evaluation was due by 2/5/18 but was not documented at the time of the licensing inspection.
Client #6 was admitted on 4/6/05 and was an active client at the time of the licensing inspection. An annual clinical evaluation was documented on 9/27/16; another annual evaluation was due by 9/27/17 but was not documented at the time of the licensing inspection.
Client #11 was admitted on 3/8/04 and discharged on 11/3/17. No annual clinical evaluation was documented in the client record.
Client #12 was admitted on 9/1/15 and discharged on 11/15/17. No annual clinical evaluation was documented in the client record.
Client #14 was re-admitted on 12/8/14 and discharged on 1/16/18. No annual clinical evaluation was documented in the client record.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 8/1/2018 The Clinical Supervisor will be responsible for placing the client's admit date in the tracker. The clinician will be responsible for completing the Annual Evaluation with the client on or before the anniversary of the client's admit date and submitting the packet to the clinical supervisor. The clinical supervisor will be responsible for reviewing the submission and documenting having received the Annual Evaluation in the tracker. The clinical supervisor will be responsible for submitting the Annual Evaluation to the Medical Records Department. The medical records clerk will attach the packet to the client's treatment chart. The Clinical manager will be responsible to review this process in supervision with the clinical supervisors.
The Division Director hired a QA person who will be responsible for building a more responsive documentation tracker. The QA person will support the clinicians by providing timely information alerts regarding due dates and timely follow up for documents which will be submitted directly to him.
The Annual Evaluations for Client #4 and #6 will be completed by 8/31/18 |
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
Fourteen client records were reviewed on June 14-15, 2018; the facility failed to update the treatment plan every 60 days in eight of fourteen client records.
Client #1 was admitted on 6/12/17 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 12/20/17; a treatment plan update was due by 2/20/18 but was not documented until 5/15/18.
Client #3 was admitted on 10/26/17 and discharged on 5/19/18. A comprehensive treatment plan was documented on 10/27/17; a treatment plan update was due by 12/27/17 but was not documented at the time of the inspection.
Client #5 was admitted on 10/10/17 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 12/14/17; a treatment plan update was due by 2/14/18 but was not documented at the time of the inspection.
Client #7 was admitted on 2/12/10 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 9/19/17; a treatment plan update was due by 11/19/17 but was not documented until 12/20/17; additionally, another update was due by 2/20/18 but was not documented until 6/1/18.
Client #8 was admitted on 12/19/17 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 2/1/18; a treatment plan update was due by 4/1/18 but was not documented until 4/12/18; additionally, another update was due by 6/12/18 but was not documented at the time of the inspection.
Client #9 was admitted on 9/16/10 and was an active client at the time of the licensing inspection. A treatment plan update was documented on 4/5/18; a treatment plan update was due by 6/5/18 but was not documented at the time of the inspection.
Client #12 was admitted on 9/1/15 and discharged on 11/15/17. A treatment plan update was documented on 6/30/17; a treatment plan update was due by 8/30/17 but was not documented until 10/27/17.
Client #13 was admitted on 12/19/17 and discharged on 5/25/18. A treatment plan update was documented on 1/30/18; a treatment plan update was due by 3/30/18 but was not documented at the time of the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Effective 8/13/18: The Treatment Plan dates for clients #1,#3, #5, #7, #8, #9, will all be brought up to date. The clinical manager will be responsible to ensure that this assignment is completed.
Effective 8/20/18 The Division Director hired a QA person for the program who will build a more effective tracking system. The QA person will be responsible for tracking Treatment Plan Dates, providing weekly information and support for the clinicians to schedule and complete timely Treatment Planning sessions with members. The Clinical Manager and the Division Director will be responsible to ensure this objective is completed and will monitor in monthly supervision meetings.
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