INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 12, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, GPHA Dental and Behavioral Health Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
The facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor during the first six months of employment in that position in one of one applicable personnel record.Employee # 3 was hired as a Clinical Supervisor on January 2, 2018. Monthly supervision notes were required for the months of June 2018 and July 2018; however, there was no documentation of monthly supervision provided for the months required.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
704.6(c) LICENSURE - SUPERVISORY MEETINGS
704.6 Qualifications for the position of clinical supervisor.
CORRECTIVE ACTION:
In an effort to establish and maintain full compliance with regulation 704.6(c), the findings from the June 12, 2019, survey were reviewed by the Chief Behavioral Healthcare Officer, Site Director of Behavioral Health and Clinical Supervisor. As a result, Supervision notes that were presented in the audit of June 21, 2018, that covered supervision meetings for the first six months of employment for employee #3 were placed back in the current clinical supervision binder. To avoid future discrepancies regarding regulation 704.6 (c), supervision meeting notations for Clinical supervisors will be maintained in the general supervision binder and available for review during at minimum 2-DDAP Audits.
This process has been implemented and will be monitored by the Quality Assurance Manager.
Monitoring: On-going
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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
The facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The female bathroom located in the lobby had a clogged sink.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
705.24(7) LICENSURE - BATHROOM
705.24 (7) The nonresidential facility shall: Maintain each bathroom in a functional, clean and sanitary manner at all times.
CORRECTIVE ACTION:
In an effort to establish and maintain full compliance with regulation 705.24(7), the findings from the June 12, 2019, survey were reviewed by the Chief Behavioral Healthcare Officer, Site Director of Behavioral Health and Clinical Supervisor. As a result, The Maintenance Director was contacted to discuss the finding and to offer a reasonable solution to ensure compliance of regulation 705.24 (7). Effective immediately, any work order submitted to the maintenance department regarding bathroom sinks or toilets will be responded to within 24-hours of receiving the work order with the exception of running or flowing water which will be addressed immediately with the assistance of onsite security, followed by maintenance within 20-minutes of the telephone notification. In addition, monthly maintenance will be conducted to ensure proper water flow.
Correction Time: Completed
Monitoring: Daily monitoring by security, Ongoing monthly maintenance by the Maintenance Department, findings reviewed by the EOC committee monthly and audited by the QA Department Quarterly. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in one of one client record.Client #6 was admitted on July 19, 2018 and was discharged on March 26, 2019. The facility's written procedure manual stated that the master treatment plan must be developed within 15 work days from the date of admission; however, the treatment plan for this client was not developed until October 26, 2018.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.24 (a) (3) LICENSURE
Treatment/rehabilitation management.:
A meeting is scheduled today, July 19, 2019, with the Clinical Team to review 709.24 (a)(3) LICENSURE Treatment Rehabilitation Management: To ensure that each Client have a Treatment/ Rehabilitation Plan as outlined in our policy and within the timeframe stated in out policy. Comprehensive Treatment Plans are required within 15-business days after intake admission. Along with a refresher on:
- Documenting the type and frequency of treatment and rehabilitative services
- The time-line for completing Treatment Plan Updates.
- The need to complete the comprehensive treatment plan on behalf of the Client in the event the Client fails to attend the scheduled session.
Treatment plan completed absent of the Client will be signed by the Clinician, Clinical Supervisor and Psychiatrist and maintained in draft mode until the Client's next kept appointment
- Any requested revisions will be updated at the time of the Clients
Monitoring: The Quality Assurance Clerk will conduct daily audits along with audits based on the Clients' schedule 48-hours in advance to ensure Treatment Plan time lines are in compliance.
The Clinical Supervisor will conduct weekly reviews to ensure that all aspects of the treatment plan is in compliance with standard 709.24.
TIME FRAME FOR COMPLETION:
July 19, 2019
? Ongoing Monitoring
Evaluation of Monitoring Process
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to ensure that the personnel records contained documentation of an annual written individual performance evaluation in one of three applicable employee records reviewed.Employee # 5 was hired as a counselor on November 8, 2017. There was no documentation of an annual written individual performance evaluation completed during the review year of 2018.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Correction Time: Complete
Monitoring - ongoing
Plan of Correction:
Standard in non-compliance 709.26 (b) (3) PERSONNEL MANAGEMENT:
§ 709.26. Personnel management.
To comply with Standard 709.26(b)(2) Personnel Management the annual review date will be required on all supervision notes as a reminder and to reference goals outlined during the previous evaluation period. In addition to the Clinical Supervisor receiving electronic notification from Performance Pro (Personnel Management Software) of pending annual performance reviews 45-days prior to the due date, along with weekly automatic reminders, the site directors will have a hard copy of all pending annual performance reviews. Performance reviews that are not attempted or pending finalization within 24-hours will be sent with high alert to the Supervisor and Site Director. Notification of pending failure to meet the annual performance evaluation due date will be forwarded to the Chief Behavioral Healthcare Officer resulting in a written reprimand and mandatory completion prior to the end of business.
Correction Time: 07/26/2019
Monitoring ? HR Department will manually monitor this process monthly, daily monitoring occurs through Performance Pro, Supervisor will monitor due dates during supervision sessions, Site Directors will monitor compliance weekly. The QA Department will conduct random audits of the process and compliance and make any necessary adjustments to maintain compliance.
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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
The facility failed to document the purpose of disclosure on consent to release information forms in two of six client records.Client # 3 was admitted on February 28, 2019 and was active at the time of the inspection. There was a consent form to the funding source signed and dated by the client on February 28, 2019; however, the consent to release form listed the purpose of disclosure as "release of information."Client # 4 was admitted on August 13, 2018 and was discharged on May 30, 2019. There was a consent form to the funding source signed and dated by the client on August 13, 2018; however, the consent to release form listed the purpose of disclosure as "release of information."The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Noncompliance
709.28 (c)(3) Licensure
Confidentiality:
To comply with regulation 709.28 (c)(3), the written findings from the June 12, 2019 were reviewed in detail with the Clinical Team, and QA EHR Specialist. As a result of the meeting, the electronic consent form has been revised removing the error "release of information" as a dropdown option listed under purpose of disclosure.
It has been replaced with the following options under Purpose of disclosure: Authorize Care, Facilitate Claims, Monitor Services, Continuity of Care, Service Transfer, SSI/SSDI Review, Court Compliance and Other, which requires specification.
The Clinical team is scheduled for training today, July 19, 2019. The QA EHR Specialist will be available to assist the Clinical team if needed regarding the form revision.
A random audit of each therapist caseload will be conducted periodically by the Clinical Supervisor to ensure that standard 709.28 (c)(3) is being followed properly. Therapist found deficient in this area will receive immediate retraining.
Correction Time: Correction July 19. 2019. Monitoring On-going
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709.28 (c) (5) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
The facility failed to document a dated witness signature on every consent to release information form in each client record reviewed.Client # 1 was admitted on May 8, 2018 and was still active at the time of the inspection.Client # 2 was admitted on January 10, 2019 and was still active at the time of the inspection.Client # 3 was admitted on February 28, 2019 and was still active at the time of the inspection.Client # 4 was admitted on August 13, 2018 and was discharged on May 30, 2019.Client # 5 was admitted on November 2, 2018 and was discharged on May 31, 2019.Client # 6 was admitted on July 19, 2018 and was discharged on March 26, 2019.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Noncompliance
709.28 (c)(5) Confidentiality:
To comply with regulation 709.28 (c)(5), the written findings from the June 12, 2019 were reviewed in detail with the Clinical Team, IT Department along with our Electronic Health Record Client Alignment Representative. As a result of the meeting, it was again confirmed that the systems electronic signature process met the conditions necessary for electronic signatures under HIPAA law and in consideration of the Uniform Electronic Transaction Act (UETA) and the Global and National Commerce Act (ESIGN Act) is in full compliance.
However, to maintain compliance with ESIGN and add instant visual compliance for regulation 709.28 (c) (5) an additional field will be added to the existing electronic consent forms indicating the language Dated signature of witness. This field will be mandatory. Therefore, it is impossible to bypass the field. The revision date will not exceed July 31, 2019. The Clinical team is scheduled for training this afternoon July 19, 2019, on the revised field. The QA EHR Specialist will be available to assist the Clinical team if needed regarding the additional field. A random audit of each therapist caseload will be conducted periodically by the Clinical Supervisor to ensure that standard 709.28 is being followed properly.
Correction Time: Correction July 31. 2019, this date allows for testing and any IT revisions that may be needed. Monitoring On-going
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to provide documentation verifying that each client record reviewed had given written acknowledgement that they had been informed that as a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107), they shall retain all their civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Noncompliance
709.30 (3) LICENSURE
Client rights:
§ 709.30. Client rights.
To meet and maintain compliance with regulation 709.30 (3), A meeting was held with the Clinical Team as a result, The QA EHR Specialist was contacted and asked to resolve the error. Within 48 hours of the audit, the Electronic Client Rights and Responsibility Form viewed during the audit in which, Clinicians had read/write privileges was restricted, giving them read rights only. The correct electronic Client Rights and Responsibility form was enabled. The current electronic Client Rights and Responsibility from meets the full requirements of 709.30 particularly 709.30 (3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
The disabling of the incorrect form and enabling of the correct form was confirmed by the QA Department and Clinical Team.
The QA Department along with the Site Directors will conduct on going monitoring at minimum every 30-days for the first 90-days and quarterly thereafter to ensure that correct electronic forms are being used and obsolete and/or faulty forms are disabled. Data collected during these audits will be immediately shared with the Clinical Leadership Team and QA EHR Specialist for immediate resolve if needed.
Completion Time: Completed
Monitoring: On-going
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709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
The facility failed to provide documentation verifying that each client record reviewed had given written acknowledgement that they had been informed that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if that director determines that the information may be detrimental if presented to the client and the reasons for the removal of such sections shall be documented in the record.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Noncompliance
709.30 (3) LICENSURE
Client rights:
§ 709.30. Client rights.
To meet and maintain compliance with regulation 709.30 (3), A meeting was held with the Clinical Team as a result, The QA EHR Specialist was contacted and asked to resolve the error. Within 48 hours of the audit, the Electronic Client Rights and Responsibility Form viewed during the audit in which, Clinicians had read/write privileges was restricted, giving them read rights only. The correct electronic Client Rights and Responsibility form was enabled. The current electronic Client Rights and Responsibility from meets the full requirements of 709.30 particularly 709.30 (3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
The disabling of the incorrect form and enabling of the correct form was confirmed by the QA Department and Clinical Team.
The QA Department along with the Site Directors will conduct on going monitoring at minimum every 30-days for the first 90-days and quarterly thereafter to ensure that correct electronic forms are being used and obsolete and/or faulty forms are disabled. Data collected during these audits will be immediately shared with the Clinical Leadership Team and QA EHR Specialist for immediate resolve if needed.
Completion Time: Completed
Monitoring: On-going |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The facility failed to provide documentation verifying that each client record reviewed had given written acknowledgement that they had been informed that all clients have the right to appeal, to the director, a decision limiting access to their records.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Noncompliance
709.30 (4) LICENSURE
Client rights:
§ 709.30. Client rights.
To meet and maintain compliance with regulation 709.30 (4), A meeting was held with the Clinical Team as a result, The QA EHR Specialist was contacted and asked to resolve the error. Within 48 hours of the audit, the Electronic Client Rights and Responsibility Form viewed during the audit in which, Clinicians had read/write privileges was restricted, giving them read rights only. The correct electronic Client Rights and Responsibility form was enabled. The current electronic Client Rights and Responsibility from meets the full requirements of 709.30 particularly 709.30 (4) Clients have the right to appeal a decision limiting access to their records to the director.
The disabling of the incorrect form and enabling of the correct form was confirmed by the QA Department and Clinical Team. The QA Department along with the Site Directors will conduct on going monitoring at minimum every 30-days for the first 90-days and quarterly thereafter to ensure that correct electronic forms are being used and obsolete and/or faulty forms are disabled. Data collected during these audits will be immediately shared with the Clinical Leadership Team and QA EHR Specialist for immediate resolve if needed.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
The facility failed to provide documentation verifying that each client record reviewed had given written acknowledgement that they had been informed that all clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard in Noncompliance
709.30 (5) LICENSURE
Client rights:
§ 709.30. Client rights.
To meet and maintain compliance with regulation 709.30 (5), A meeting was held with the Clinical Team as a result, The QA EHR Specialist was contacted and asked to resolve the error. Within 48 hours of the audit, the Electronic Client Rights and Responsibility Form viewed during the audit in which, Clinicians had read/write privileges was restricted, giving them read rights only. The correct electronic Client Rights and Responsibility form was enabled. The current electronic Client Rights and Responsibility from meets the full requirements of 709.30 particularly 709.30 (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
The disabling of the incorrect form and enabling of the correct form was confirmed by the QA Department and Clinical Team. The QA Department along with the Site Directors will conduct on going monitoring at minimum every 30-days for the first 90-days and quarterly thereafter to ensure that correct electronic forms are being used and obsolete and/or faulty forms are disabled. Data collected during these audits will be immediately shared with the Clinical Leadership Team and QA EHR Specialist for immediate resolve if needed.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to document a psychosocial evaluation in three of six client records reviewed.Client # 4 was admitted on August 13, 2018 and was discharged on May 30, 2019.Client # 5 was admitted on November 2, 2018 and was discharged on May 31, 2019.Client # 6 was admitted on July 19, 2018 and was discharged on March 26, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.91(b)(6) LICENSURE
Intake and Admission:
In an effort to regain and maintain full compliance with regulation 709.91(b)(6), the findings from June 12, 2019, were reviewed by the Chief Behavioral Healthcare Officer, Site Director, Clinical Supervisor and QA Manager. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented.
A meeting has been scheduled for today, July 19, 2019, with the Clinical Team to review Standard 709.91(b)(6) LICENSURE Intake and Admission with focus on: Summarizing the data gathered during the Comprehensive Biopsychosocial Evaluation immediately following the completion of the document.
Along with a refresher on: On ensuring that the required data identified in regulation 709.91 (b) (6) is included in the psychosocial evaluation summary.
Monitoring: The Quality Assurance Clerk will conduct weekly audits based on scheduled CBE appointments to ensure a psychosocial evaluation summary has been completed. Any Non-Compliance will be emailed to both the Clinician and supervisor for immediate correction. The Clinical Supervisor will conduct weekly reviews to ensure that all aspects of the 709.91 is in compliance with standard 709.91 (b) (c).
TIME FRAME FOR COMPLETION:
July 19, 2019 ? Ongoing Monitoring
Evaluation of Monitoring Process
Every 30-days by Quality Assurance Manager and Site Director will conduct targeted audits to ensure compliance.
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to properly document the frequency of services that the client was to receive on the client's individual treatment plan in two of six client records reviewed. Client # 2 was admitted on January 10, 2019 and was active at the time of inspection. The comprehensive treatment plan was dated January 22, 2019.Client # 3 was admitted on February 28, 2019 and active at the time of the inspection. The comprehensive treatment plan was dated February 28, 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(a) (2) LICENSURE
TREATMENT AND REHABILITATION SERVICES:
Plan of Correction:
In an effort to regain and maintain full compliance with regulation 709.92(a) (2), the findings from the June 12, 2019, were reviewed by the Chief Behavioral Healthcare Officer, Site Director and clinical supervisor. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented.
A meeting has been scheduled for July 19, 2019, with the Clinical Team to review 709.92 (a)(2) LICENSURE Treatment and Rehabilitation with focus on required time-lines for completing the comprehensive treatment plan and effective and timely documentation and treatment planning processes: Along with a refresher on:
- Documenting the type and frequency of treatment and rehabilitative services
- The time-line for completing the comprehensive treatment plan (Required 15-business days after Intake as indicated in policy)
- The need to complete the comprehensive treatment plan on behalf of the Client in the event the Client fails to attend the scheduled session. Treatment plan will be signed by the Clinician, Clinical Supervisor and Psychiatrist and maintained in draft mode until the Client's next kept appointment
- Any requested revisions will be updated at the time of the Clients kept appointment, signed by the Client and finalized by the team.
Monitoring: The Quality Assurance Clerk will conduct daily audits along with audits based on the Clients' schedule 48-hours in advance to ensure Treatment Plan time lines are in compliance.
The Clinical Supervisor will conduct weekly reviews to ensure that all aspects of the treatment plan is in compliance with standard 709.92.
TIME FRAME FOR COMPLETION:
July 19, 2019
? Ongoing Monitoring
Evaluation of Monitoring Process
Every 60-days by Quality Assurance Manager and Site Director |
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
The facility failed to provide treatment plan updates within the regulatory timeframe in five of six applicable client records reviewed.Client # 1 was admitted on May 8, 2018 and was still active at the time of the inspection. A treatment plan update was completed on January 22, 2019 with an update due no later than March 22, 2019; however, the update was completed on May 23, 2019.Client # 3 was admitted on February 28, 2019 and was still active at the time of the inspection.A treatment plan update was completed on March 27, 2019 with an update was due no later than May 27, 2019; however, the update was completed on June 10, 2019.Client # 4 was admitted on August 13, 2018 and was discharged on May 30, 2019. The comprehensive treatment and rehabilitation plan was completed on August 13, 2018 with an update was due no later than October 13, 2018; however, the update was completed on January 28, 2019. Additionally, another update was due no later than March 28, 2019; however, it was not completed until May 30, 2019.Client # 5 was admitted on November 2, 2018 and was discharged on May 31, 2019. The comprehensive treatment and rehabilitation plan was completed on November 26, 2018 with an update was due no later than January 26, 2019; however, no update was completed prior to discharge.Client # 6 was admitted on July 19, 2018 and was discharged on March 26, 2019. The comprehensive treatment and rehabilitation plan was completed on October 26, 2018 with an update was due no later than December 26, 2018; however, no update was completed prior to discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92 (b) LICENSURE
TREATMENT AND REHABILITATION SERVICES:
In an effort to regain and maintain full compliance with regulation 709.92(b) the findings from the June 12, 2019, were reviewed by the Chief Behavioral Healthcare Officer, Site Director and Clinical Coordinator. As a result of the findings and full review of the cases found in non-compliance the following corrective action plan has been implemented.
A meeting has been scheduled for July 19, 2019, with the Clinical Team to review Standard 709.92(b) Licensure Treatment and Rehabilitation: Treatment Plan with a focus on required time-lines for initiating and updated Treatment Plans: How to handle compliant clients and non-compliant clients when Treatment Plans are due and up for review.
Along with a refresher on:
- Developing Comprehensive Treatment Plans
- Developing Treatment Plans Up-Dates
- The Treatment Plan Update will be completed 60 days after first Comprehensive Treatment Plan
- Clients that fail to keep scheduled appointments within the above timeframe will have a treatment plan update developed on their behalf by the assigned clinician. Said treatment plan will be signed by the Clinician, Clinical Supervisor and Site Psychiatrist and reviewed with Client at the next kept appointment
- Any requested revisions will be updated, signed and finalized at the time of the Clients next kept appointment.
Monitoring: The Quality Assurance Clerk will conduct daily audits along with audits based on the Clients' schedule 48-hours in advance to ensure that Treatment Plans are updated in accordance with regulation 709.92 and policy. The Clinical Supervisor will conduct weekly reviews to ensure that all aspects of the treatment plan is in compliance with standard 709.92.
TIME FRAME FOR COMPLETION:
July 19, 2019 ? Ongoing Monitoring
Evaluation of Monitoring Process
Every 60-days by Quality Assurance Manager and Site Director |