INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on January 22, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sarah Jane Bentley Foundation 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of the facility's staff development program and a discussion with facility staff, the facility failed to develop a mechanism to collect feedback on completed trainings. This finding was reviewed with the facility staff during the licensing process.This is a repeat citation from the October 2, 2023 licensing inspection
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Plan of Correction
On 02/26/24, the facility office manager created a new Human Resources form titled "Employee Training Evaluation." The facility office manager will distribute this form to all staff members before filing any "certificates of completion" for training in the HR files. Ongoing. The CEO will also review these forms when developing the annual training plan for the facility. Date of completion: 03/15/2024 |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as a counselor was holding a counseling session with the door open. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Sarah Jane Bentley Foundation requires that staff members provide clinical services behind a closed door, and when possible, to also have a sound canceling device activated in the hallway outside of the counseling room. The CEO will provide all staff members with in-service training reminding them of this requirement by Friday, March 22, 2023. Staff members will be required to acknowledge their understanding of this requirement. The office manager, CEO, and Clinical Supervisor will conduct random, unannounced walkthroughs of clinical areas daily to ensure ongoing compliance with this requirement. Date of completion: 03/22/2024 |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the December 2023 through January 2024 fire drill logs, the facility failed to document whether the fire alarm or smoke detector was operative.This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the October 2, 2023 licensing inspection.
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Plan of Correction
The Sarah Jane Bentley Foundation operates its licensed outpatient treatment services in a mixed-use commercial building that houses other tenants. As a result, the facility has been unable to activate the fire alarm during routine fire drills. The CEO will prepare an exception request to submit to the Bureau of Drug and Alcohol Programs that includes the installation of a non-wired smoke detector that can be activated to conduct fire drills in the rented space. The exception request will be forwarded to the department no later than Friday, March 22, 2023. If approved, the office manager will announce all fire drills using the battery-operated/non-wired smoke detector for drills. The use of this will also be documented on the fire drill form. To prevent a recurrence, the office manager has been trained on the need to complete the form in its entirety, and the CEO will monitor the fire drill log quarterly to ensure compliance. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the December 2023 through January 2024 fire drill logs, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill. This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the October 2, 2023 licensing inspection.
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Plan of Correction
The Sarah Jane Bentley Foundation operates its licensed outpatient treatment services in a mixed-use commercial building that houses other tenants. As a result, the facility has been unable to activate the fire alarm during routine fire drills. The CEO will prepare an exception request to submit to the Bureau of Drug and Alcohol Programs that includes the installation of a non-wired smoke detector that can be activated to conduct fire drills in the rented space. The exception request will be forwarded to the department no later than Friday, March 22, 2023. If approved, the office manager will announce all fire drills using the battery-operated/non-wired smoke detector for drills. The use of this will also be documented on the fire drill form. To prevent a recurrence, the office manager has been trained on the need to complete the form in its entirety, and the CEO will monitor the fire drill log quarterly to ensure compliance. |
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
The facility failed to ensure that all client records are kept within a locked storage container. Upon arrival at the facility, the facility ' s records were in an unlocked cabinet in an unlocked room. These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Sarah Jane Bentley Foundation management team has procured keys for all file cabinets. All file cabinets are now in the office manager's office, which has been added to the floor plan. This office will remain locked when unattended, ensuring the files are in a locked cabinet in a locked room. At all times these cabinets will be locked. Only the office manager or Director can access a paper file. To prevent a recurrence, The director will periodically tour the facility and ensure all doors and cabinets are locked. Additionally, the new EHR will make the foundation paperless for patient charts. It also requires 2-factor authentication at terminals, preventing unauthorized access.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency, or organization to whom disclosure is made in six of the seven records reviewed. Client # 2 was admitted on July 25, 2023, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information back-dated July 25, 2023 did not provide the name of the person, agency or organization to whom the disclosure can be made. Client #3 was admitted on July 5, 2023 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information back-dated July 5, 2023 did not provide the name of the person, agency or organization to whom the disclosure can be made.Client #4 was admitted on August 4, 2023 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information back-dated August 10, 2023 did not provide the name of the person, agency or organization to whom the disclosure can be made. Client #6 was admitted on September 27, 2023, and was discharged on November 6, 2023. An informed and voluntary consent from the client for the disclosure of information back-dated September 27, 2023 did not provide the name of the person, agency or organization to whom the disclosure can be made. Client # 7 was admitted on October 31, 2023, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated October 31, 2023 did not provide the name of the person, agency or organization to whom the disclosure can be made. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Sarah Jane Bentley Foundation was utilizing an electronic health record solution that did not contain all of the required fields for a PA-compliant release of information document. Accordingly, consent forms were being prepared external of the electronic health record, a practice that allowed for errors in the clinical documentation. Accordingly, the CEO, office manager, Clinical Supervisor, and a hired consultant reviewed and evaluated multiple Electronic Health record platforms. The team included information learned from these audits to inform the vendors that information regarding the name of the person, agency, or organization was a mandatory field to create a valid consent. The management team and consultant selected a new electronic health record vendor. The system is currently being configured and will go live on 04/01/2024. The system will not allow a consent form to be created without having data entered into the mandatory form fields, thereby preventing recurrence. In the meanwhile, staff members have been provided an in-service training related to confidentiality and the components of a valid consent form, and all staff members in need were scheduled for confidentiality training through the commonwealth DDAP training system. |
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 client records, the facility failed to ensure that all consent to release forms contained the specific information to be released in client records four of seven records reviewed. Client # 2 was admitted on July 25, 2023, and was still active at the time of the inspection. A blank informed and voluntary consent from the client for the disclosure of information back-dated July 25, 2023 did not include specific information released.Client #3 was admitted on July 5, 2023 and was still active at the time of the inspection. A blank informed and voluntary consent from the client for the disclosure of information back-dated July 5, 2023 did not include specific information released. Client #4 was admitted on August 4, 2023 and was still active at the time of the inspection. A blank informed and voluntary consent from the client for the disclosure of information back-dated August 10, 2023 did not include specific information released. Client #6 was admitted on September 27, 2023, and was discharged on November 6, 2023. A blank informed and voluntary consent from the client for the disclosure of information back-dated September 27, 2023 did not include specific information released. These findings were discussed with Facility staff during the inspection process.
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Plan of Correction
The Sarah Jane Bentley Foundation was utilizing an electronic health record solution that did not contain all of the required fields for a PA-compliant release of information document. Accordingly, consent forms were being prepared external of the electronic health record, a practice that allowed for errors in the clinical documentation. Accordingly, the CEO, office manager, Clinical Supervisor, and a hired consultant reviewed and evaluated multiple Electronic Health record platforms. The team included information learned from these audits to inform the vendors that information regarding the specific information disclosed was required to create a valid consent. The management team and consultant selected a new electronic health record vendor. The system is currently being configured and will go live on 04/01/2024. The system will not allow a consent form to be created without having data entered into the mandatory form fields, thereby preventing recurrence. In the meanwhile, staff members have been provided an in-service training related to confidentiality and the components of a valid consent form, and all staff members in need were scheduled for confidentiality training through the commonwealth DDAP training system. |
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 client records, the facility failed to ensure that all consent to release forms contained the purpose of the disclosure in six out of seven client records reviewed. Client #2 was admitted on July 25, 2023, and was still active at the time of the inspection. An informed and voluntary consent for the funding source for the disclosure of information back-dated July 25, 2023 did not provide the purpose of the release. Client #3 was admitted on July 5, 2023 and was still active at the time of the inspection. An informed and voluntary consent for emergency contact or the disclosure of information back-dated July 5, 2023 did not provide the purpose of the release. Client #4 was admitted on August 4, 2023 and was still active at the time of the inspection. A blank informed and voluntary consent and a release for an outside agency for the disclosure of information back-dated August 10, 2023 did not provide the purpose of the release.Client #5 was admitted on August 17, 2023 and was discharged on an unknown date. An informed and voluntary consent for an outside agency for the disclosure of information back dated August 17, 2023 did not provide the purpose of the release. Client #6 was admitted on September 27, 2023, and was discharged on November 6, 2023. A blank informed and voluntary consent from the client for the disclosure of information back-dated September 27, 2023 did not provide the purpose of the release. Client # 7 was admitted on October 31, 2023, and was still active at the time of the inspection. An informed and voluntary consent for outside agencies for the disclosure of information dated October 31, 2023 did not provide the purpose of the release. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The Sarah Jane Bentley Foundation was utilizing an electronic health record solution that did not contain all of the required fields for a PA-compliant release of information document. Accordingly, consent forms were being prepared external of the electronic health record, a practice that allowed for errors in the clinical documentation. Accordingly, the CEO, office manager, Clinical Supervisor, and a hired consultant reviewed and evaluated multiple Electronic Health record platforms. The team included information learned from these audits to inform the vendors that information regarding the purpose of the disclosure was required to create a valid consent. The management team and consultant selected a new electronic health record vendor. The system is currently being configured and will go live on 04/01/2024. The system will not allow a consent form to be created without having data entered into the mandatory form fields, thereby preventing recurrence. In the meanwhile, staff members have been provided an in-service training related to confidentiality and the components of a valid consent form, and all staff members in need were scheduled for confidentiality training through the commonwealth DDAP training system. |
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 client records and discussion with facility staff, the facility failed to accurately document the dated signature of clients in five of seven client records reviewed.During the previous licensing inspection on October 2, 2023, the facility was cited for not obtaining consent to release information forms to the funding sources of all clients reviewed. During this follow-up inspection, there were signed consent to release information forms to the funding sources in all client records reviewed. However, in five client records, the dates of when the clients signed the release form were the dates of each client ' s admission; which was prior to the previous licensing inspection. Facility staff confirmed the inaccuracies of the clients ' signatures and dates and per 42 CFR Part 2.31(a)(9), a written consent must include the date on which the consent is signed. Client # 2 was admitted on July 25, 2023, and was still active at the time of the inspection The consent to release information form to the funding source had a dated signature of July 25, 2023. Client #3 was admitted on July 5, 2023 and was still active at the time of the inspection. The consent to release information form to the funding source had a dated signature of July 5, 2023. Client #4 was admitted on August 4, 2023 and was still active at the time of the inspection The consent to release information form to the funding source had a dated signature of August 4, 2023 Client #5 was admitted on August 17, 2023 and was discharged on an unknown date. The consent to release information form to the funding source had a dated signature of August 17, 2023.Client #6 was admitted on September 27, 2023, and was discharged on November 6, 2023. The consent to release information form to the funding source had a dated signature of September 27, 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Sarah Jane Bentley Foundation was utilizing an electronic health record solution that did not contain all of the required fields for a PA-compliant release of information document. Accordingly, consent forms were being prepared external to the electronic health record, a practice that allowed for errors in the clinical documentation. Accordingly, the CEO, office manager, Clinical Supervisor, and a hired consultant reviewed and evaluated multiple Electronic Health record platforms. The team included information learned from these audits to inform the vendors the information regarding the contents required to create a valid consent. The management team and consultant selected a new electronic health record vendor. The system is currently being configured and will go live on 04/01/2024. The system will not allow a consent form to be back-dated, thereby preventing recurrence. In the meanwhile, staff members have been provided an in-service training related to confidentiality and the components of a valid consent form, and all staff members in need were scheduled for confidentiality training through the commonwealth DDAP training system. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the clients that recorded the date, event, or condition upon which the consent will expire in three out of seven records reviewed.Client #2 was admitted on July 25, 2023, and was still active at the time of the inspection. A blank release of information form back- dated July 25, 2023 did not document when the consents will expire.Client #3 was admitted on July 5, 2023 and was still active at the time of the inspection. A blank release of information form back- dated July 5, 2023 did not document when the consents will expire.Client # 7 was admitted on October 31, 2023, and was still active at the time of the inspection. A blank release of information form dated October 31, 2023 did not document when the consents will expire.These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Sarah Jane Bentley Foundation was utilizing an electronic health record solution that did not contain all of the required fields for a PA-compliant release of information document. Accordingly, consent forms were being prepared external of the electronic health record, a practice that allowed for errors in the clinical documentation. Accordingly, the CEO, office manager, Clinical Supervisor, and a hired consultant reviewed and evaluated multiple Electronic Health record platforms. The team included information learned from these audits to inform the vendors that information regarding the contents required to create a valid consent. The management team and consultant selected a new electronic health record vendor. The system is currently being configured and will go live on 04/01/2024. The system will not allow a consent form to be created without an expiration date or event, thereby preventing recurrence. In the meanwhile, staff members have been provided an in-service training related to confidentiality and the components of a valid consent form, and all staff members in need were scheduled for confidentiality training through the commonwealth DDAP training system. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in two out of seven client records reviewed. Client #2 was admitted on July 25, 2023, and was still active at the time of the inspection. A blank release of information form back- dated July 25, 2023, did not have documentation that the client was offered a copy of the consent form. Client #6 was admitted on September 27, 2023, and was discharged on November 6, 2023. A blank release of information form back-dated September 27, 2023, did not have documentation that the client was offered a copy of the consent form. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Response The Sarah Jane Bentley Foundation was utilizing an electronic health record solution that did not contain all of the required fields for a PA-compliant release of information document. Accordingly, consent forms were being prepared external to the electronic health record, a practice that allowed for errors in the clinical documentation. Accordingly, the CEO, office manager, Clinical Supervisor, and a hired consultant reviewed and evaluated multiple Electronic Health record platforms. The team included information learned from these audits to inform the vendors the information regarding the contents required to create a valid consent. The management team and consultant selected a new electronic health record vendor. The system is currently being configured and will go live on 04/01/2024. The system will not allow a consent form to be created without the clinician choosing whether or not the patient has accepted or rejected a copy of the consent form, thereby preventing recurrence. In the meanwhile, staff members have been provided an in-service training related to confidentiality and the components of a valid consent form, and all staff members in need were scheduled for confidentiality training through the commonwealth DDAP training system. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on conversations with facility staff, the facility failed to develop a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives. At the time of the inspection and post inspection, the facility was unable to provide requested documentation in a timely fashion to include attestations, the Staffing Requirements Facility Summary Report and the Data Collection Report. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Unfortunately, during the State's unannounced visit, the all-in-one scan/copy/fax machine in the office became irreparably damaged.
The forms that were required to be sent could not be sent from the facility until a replacement device was received. In the meanwhile, to send the requested information to DDAP, the CEO went to the local Staples office to send the forms via fax. The submission did not contain all the required information.
A new fax/scan/copier was purchased for the facility on _02/01/2024____ and is now able to be used to transmit documentation.
The facility will ensure the operability of this device.
We do not expect a recurrence of this deficiency.
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709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on a review of client records and discussion with facility staff, the facility's record keeping system did not allow for the identification of client's admission and discharges within a specific time period. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 2, 2023 licensing inspection
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Plan of Correction
Unfortunately, during the State's unannounced visit, the all-in-one scan/copy/fax machine in the office became irreparably damaged.
The forms that were required to be sent could not be sent from the facility until a replacement device was received. In the meanwhile, to send the requested information to DDAP, the CEO went to the local Staples office to send the forms via fax. The submission did not contain all the required information.
A new fax/scan/copier was purchased for the facility on ___02/01/2024__ and is now able to be used to transmit documentation.
The facility will ensure the operability of this device ongoing.
We do not expect a recurrence of this deficiency.
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709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in five out of five applicable records reviewed. The facility's policy and procedures manual states that a case consultation is to be completed every 60 days. Client #1 was admitted on October 23, 2023 and was still active at the time of the inspection. A case consultation was due to be completed no later than December 23, 2023; however, no case consultation was documented in the client record at the time of the inspection.Client # 2 was admitted on July 25, 2023, and was still active at the time of the inspection. A case consultation was due to be completed no later than November 25, 2023; however, no case consultation was documented in the client record at the time of the inspection.Client #3 was admitted on July 5, 2023 and was still active at the time of the inspection. A case consultation was due to be completed no later than November 5, 2023; however, no case consultation was documented in the client record at the time of the inspection.Client #4 was admitted on August 4, 2023 and was still active at the time of the inspection. . A case consultation was due to be completed no later than October 4, 2023; however, no case consultation was documented in the client record at the time of the inspection.Client # 7 was admitted on October 31, 2023, and was still active at the time of the inspection. A case consultation was due to be completed no later than December 31, 2023; however, no case consultation was documented in the client record at the time of the inspection.These findings were discussed with facility staff during the inspection process. This is a repeat citation from the October 2, 2023 licensing inspection.
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Plan of Correction
Response The Sarah Jane Bentley Foundation was utilizing an electronic health record solution that could not create a "services due schedule" to project clinical services that would be needed based on prior activity in the clinical chart. Accordingly, the CEO, office manager, Clinical Supervisor, and a hired consultant reviewed and evaluated multiple Electronic Health record platforms. The team included information learned from these audits to inform the vendors of the information regarding the contents required to create a valid consent. The management team and consultant selected a new electronic health record vendor. The system is currently being configured and will go live on 04/01/2024. The system will automatically notify the counselor and clinical supervisor of when a case consult is due, thereby preventing recurrence. In the meanwhile, staff members have been provided in-service training related to case consult requirements. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in two out of two applicable discharged records reviewed.Client #5 was admitted on August 17, 2023 and was discharged on an unknown date.Client #6 was admitted on September 27, 2023, and was discharged on November 6, 2023.This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the October 2, 2023 licensing inspection.
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Plan of Correction
The Sarah Jane Bentley Foundation was utilizing an electronic health record solution that could not create a "services due schedule" to project clinical services that would be needed based on prior activity in the clinical chart. Accordingly, the CEO, office manager, Clinical Supervisor, and a hired consultant reviewed and evaluated multiple Electronic Health record platforms. The team included information learned from these audits to inform the vendors of the information regarding the contents required to create a valid consent. The management team and consultant selected a new electronic health record vendor. The system is currently being configured and will go live on 04/01/2024. The system will automatically notify the counselor and clinical supervisor of when a case consult is due, thereby preventing recurrence. In the meanwhile, staff members have been provided in-service training related to case consult requirements. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow up information in two out of two applicable discharged records reviewed.Client #5 was admitted on August 17, 2023 and was discharged on an unknown date.Client #6 was admitted on September 27, 2023, and was discharged on November 6, 2023.This finding was reviewed with facility staff during the licensing process.This is a repeat citation from the October 2, 2023 licensing inspection.
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Plan of Correction
The Sarah Jane Bentley Foundation was utilizing an electronic health record solution that could not create a "services due schedule" to project clinical services that would be needed based on prior activity in the clinical chart. Accordingly, the CEO, office manager, Clinical Supervisor, and a hired consultant reviewed and evaluated multiple Electronic Health record platforms. The team included information learned from these audits to inform the vendors of the information regarding the contents required to create a valid consent. The management team and consultant selected a new electronic health record vendor. The system is currently being configured and will go live on 04/01/2024. The system will automatically notify the counselor and clinical supervisor of when a case consult is due, thereby preventing recurrence. In the meanwhile, staff members have been provided in-service training related to case consult requirements. |