INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on January 18-19, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Healing Way 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of eleven personnel records, it was determined that one employee hired as a counselor did not meet the educational requirements for the position.
Employee #5 was hired as a counselor on May 11, 2021 and was current in that position at the time of the inspection. At the time of the hire, the employee had a bachelor ' s degree in Business Administration, which is a non-qualifying degree for the position of counselor.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from an inspection conducted on November 19, 2020.
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Plan of Correction
THW will correct the deficiency by continuing Employee #5s emploument with a demotion to Counselor Assistant, with weekly supervision by the Clinical Supervisor. He returned to title of Counselor Assistant as of 1/18/2022.
Upon hiring, THW Program Director will verify education history and employment history, and base position title and description (counselor vs. counselor assistant), upon the pre-requisites of DDAP for the role to ensure that the new employee is qualified for the position. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
Based on a review of five applicable client records and the plans of correction from inspections conducted on November 19, 2020, January 15, 2020, November 22, 2019, and December 28, 2018, the facility failed to comply with plans of correction approved by the Department to become compliant with reviewing and updating treatment and rehabilitation plans at least every 60 days; to obtain an informed and voluntary consent from one client for the disclosure of information to include specific information disclosed; and to ensure those hired as counselors met the educational and experience required for the position.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
THW Program Director and Clinical Supervisor will work together to ensure that appropriately experienced and educated clinical staff will provide direct care to patients going forward. As of 2/1/2022, Clinical Supervisor will review treatment plan due dates for each client on a monthly basis to ensure they are created and submitted on time by clinical staff. Director and Clinical Supervisor will conduct a staff training on 2/25/2022 for all clinical and administrative staff to ensure that consent forms are adaquately and appropriately completed. |
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 a review of seven client records, the facility failed to obtain an informed and voluntary consent from one client for the disclosure of information to include the name of the person, agency, or organization to whom disclosure is made.
Client # 4 was admitted on October 2, 2014, and was discharged October 12, 2021, an informed and voluntary consent from the client for the disclosure of information signed and dated August 27, 2021, did not provide the name of the person, agency or organization to whom the disclosure can be made.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On 2/25/22 THW Clinical Supervisor and Program Director will hold a staff meeting for clinical and administrative staff to ensure that consent forms are appropriately and adequately completed. Any new staff will be trained on consent form procedures during the onboarding process, during the 1st 14 days of their employment. |
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 seven client records, the facility failed to obtain an informed and voluntary consent from one client for the disclosure of information to include specific information disclosed.
Client # 4 was admitted on October 2, 2014, and was discharged October 12, 2021, an informed and voluntary consent from the client for the disclosure of information signed and dated August 27, 2021, did not provide what specific information could be disclosed.
These findings were discussed with facility staff during the inspection process.
This is a repeat citation from an inspection completed on November 19, 2020, and January 15, 2020.
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Plan of Correction
On 2/25/22 THW Clinical Supervisor and Program Director will hold a staff meeting for clinical and administrative staff to ensure that consent forms are appropriately and adequately completed. Any new staff will be trained by THW Program Director and/or Supervisor on consent form procedures during the onboarding process, during the 1st 14 days of their employment. THW administrative staff will ensure that prior to filing or scanning documentation, it has been correctly completed. |
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 seven client records, the facility failed to obtain an informed and voluntary consent from one client for the disclosure of information that include the purpose of disclosure.
Client # 4 was admitted on October 2, 2014, and was discharged October 12, 2021, an informed and voluntary consent from the patient for the disclosure of information signed and dated August 27, 2021, did not provide purpose of disclosure.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On 2/25/22 THW Clinical Supervisor and Program Director will hold a staff meeting for clinical and administrative staff to ensure that consent forms are appropriately,adequately, and entirely completed.
Any new staff will be trained by THW Program Director and/or Supervisor on consent form procedures during the onboarding process, during the 1st 14 days of their employment.
THW administrative staff will ensure that prior to filing or scanning consent forms into patient document folders, the consent forms have been correctly and wholely completed.
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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 seven client records, the facility failed to ensure that an informed and voluntary consent to release information form included the date, event, or condition upon which the consent will expire in one record.
Client #2 was admitted on April 15, 2021 and was active at the time of inspection. The client record contained an informed and voluntary consent to release information form to the emergency contact signed by the patient on April 15, 2021, that was missing the date, event, or condition upon which the consent will expire.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/25/22 THW Clinical Supervisor and Program Director will hold a staff meeting for clinical and administrative staff to ensure that consent forms are appropriately and adequately completed. Any new staff will be trained by THW Program Director and/or Clinical Supervisor on consent form procedures during the onboarding process, during the 1st 14 days of their employment. THW administrative staff will ensure that prior to filing or scanning documentation, it has been correctly completed.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of seven patient records, the facility failed to ensure that patients receive random urinalysis at least monthly in two applicable patient records reviewed.
Patient # 2 was admitted on April 15, 2021 and was an active patient at the time of the inspection. Urine drug screens were not completed and documented for the months of October and November 2021.
Patient #4 was admitted on October 2, 2014 and discharged on October 12, 2021. A urine drug screen was not completed and documented for the month May 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our software auto schedules each patient for urine analysis.As of 2/1/2022, THW Head Nurse has been coordinating with administrative staff to ensure that each patient is scheduled for a urine anaysis on at least a monthly basis. Upon a participant's completion of urine analysis, the Head Nurse will verify in our software that the patient has been scheduled for the following urine analysis. When urine results are returned to THW, administrative/front desk staff will verify as well that each participant was scheduled for their next urine. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of seven patient records, the facility failed to ensure that the narcotic treatment physician reviewed the dosage levels at least twice a year in one patient record.
Patient #3 was admitted on February 21, 2017 and was still active at the time of the inspection. The patient record contained documentation of a dose review on March 15, 2021; However, the record contained no subsequent dose reviews.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/1/2022, Administrative/front desk staff will schedule each participant for a face to face visit with physician 6 months after their initial enrollment. THW medical director will follow the schedule set by the front desk to ensure she meets with each active participant for a 6 month dose review, as well as for their annual update. When counselor meets with participant to update their treatment plan a third time (approx 5 mos into treatment), counselor will use the scheduler to verify that the participant has a 6 month review appointment scheduled, and if they do not, counselor will schedule it with them during the session. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on a review of seven patient records, the facility failed to ensure that the narcotic treatment physician document in the patient record the rationale for permitting take-home medication in three patient records reviewed.
Patient #1 was admitted on January 28, 2021 and discharged on February 23, 2021. The patient received take-home medication January 31, 2021 through February 2, 2021 with no reason documented in the record.
Patient #2 was admitted on April 15, 2021 and was active at the time of the inspection. The patient received take-home medication May 20, 2021 through May 23, 2021, July 9, 2021 through July 11, 2021, November 25, 2021 through November 28, 2021, December 24, 2021 through December 26, 2021, and December 31, 2021 through January 2, 2021, with no reason documented in the record.
Patient #7 was admitted on April 15, 2021 and discharged on September 23, 2021. The patient received take-home medication May 7-9, 2021, June 17-21, 2021 and August 18-23, 2021 with no documented reason within the record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor will complete vacation request with the participant, and review the details and accuracy of the take home request, prior to submitting it for approval by the Medical Director. Vacation requests will require the signature of counselor, medical director, and a THW supervisor, to ensure that
THW Medical Director will ensure that vacation and take home request documentation is adequately completed, and input into software to correlate the reason for the request. Administrative/front desk staff will ensure that prior to scanning vacation request forms into patient records, all information is included. THW Program Director met with staff on 2/1/2021 to ensure that processes will be followed going forward. |
715.17(c)(3)(i-v) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
Based on a physical plant inspection on January 19, 2022, the facility failed to ensure that outdated drugs were removed and destroyed according to Federal and State regulations as nine boxes of Narcan found in the Nurse ' s Office expired in September 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/1/2022, expired NARCAN has been disposed of by Head Nurse. When conducting inventory inspection, THW Head Nurse will ensure to review first aid materials as well as NARCAN and PPD tests. Program Director has updated the MSDS spreadsheet to include NARCAN and its expiration dates. MSDS is reviewed quarterly by Program Director. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of seven records, the facility failed to ensure an annual physical reevaluation in one record reviewed.
Patient # 4 was admitted on October 2, 2014 and was discharged on October 12, 2021. The most recent annual physical evaluation was due no later than August 27, 2021; however, it was not documented in the patient record as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 2/1/22, THW administrative/front desk staff will schedule participants two weeks prior to the one year mark to ensure their compliance in keeping their set appointments. THW Medical Director will ensure to complete annual reevaluation no later than one year after admittance to the program. THW Clinical Supervisor will use existing weekly meetings to review upcoming annual due dates for each month in order to ensure the lapse in time does not occur again. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of seven patient records, the facility failed to ensure that the patient ' s counselor completed an annual evaluation and included the areas of employment, legal standing, substance abuse, financial management abilities, physical and emotional health, fulfillment of treatment objectives, and family and community support in three records reviewed.
Patient #3 was admitted on February 21, 2017 and was an active patient at the time of inspection. The most recent annual evaluation completed by the counselor was March 15, 2021 but did not include the seven required areas listed above.
Patient #4 was admitted on October 2, 2014 and was discharged on October 12, 2021. The most recent annual evaluation completed by the counselor was August 27, 2020 but did not include the seven required areas listed above.
Patient #5 was admitted on January 9, 2015 and discharged on May 5, 2021. The most recent annual evaluation completed by the counselor was June 8, 2020 but did not include the seven required areas listed above.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/28/22, THW Program Director and Clinical Supervisor held a staff meeting and refresher training about accuracy, detail, timely submission, and requirements for forms and documents. All new staff will be training by Program Director and/or Clinical Supervisor on documentation requirements within 14 days of hire. Refresher training on documentation requirements will be held for all staff on a yearly basis, with the next training being held in May 2022. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of patient records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of five applicable records reviewed.
Patient #2 was admitted on April 15, 2021 and was active at the time of inspection. A treatment plan update was completed on July 8, 2021 and a treatment plan update was due by September 8, 2021; however, the next update was not completed until September 30, 2021.
Patient #3 was admitted on February 21, 2017 and was active at the time of inspection. A treatment plan update was completed on February 10, 2021 and a treatment plan update was due by April 10, 2021; however, the next update was not completed until May 27, 2021.
Patient #5 was admitted on January 9, 2015 and was discharged on May 5, 2021. A treatment plan update was completed on November 14, 2020 and a treatment plan update was due by January 14, 2021; however, the next update was not completed until January 21, 2021.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from inspections conducted on November 19, 2020, January 15, 2020, November 22,2019, and December 28, 2018.
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Plan of Correction
On 1/28/22, THW Program Director and Clinical Supervisor held a staff meeting and refresher training about accuracy, detail, timely submission, and requirements for forms and documents. All new staff will be training by Program Director and/or Clinical Supervisor on documentation requirements within 14 days of hire. Refresher training on documentation requirements will be held for all staff on a yearly basis, with the next training being held in May 2022. |
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 patient records, the facility failed to follow their procedures for case consultation notes in that the procedure states "patients should receive a case consultation quarterly within the first year and yearly after that. " In four of five applicable records reviewed there we no case consultation notes documented per policy procedure.
Patient #2 was admitted on April 15, 2021 and was active at the time of inspection. The patient record did not contain documentation of case consultation notes.
Patient #3 was admitted on February 21, 2017 and was active at the time of inspection. The patient record did not contain documentation of case consultation notes since January 10, 2019.
Patient #5 was admitted on January 9, 2015 and discharged on May 5, 2021. The patient record did not contain documentation of case consultation notes since January 9, 2019
Patient #7 was admitted on April 15, 2021 and was discharged on September 23, 2021. The patient record did not contain documentation of any case consultation notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/28/22, THW Program Director and Clinical Supervisor held a staff meeting and refresher training about accuracy, detail, timely submission, and requirements for forms and documents. All new staff will be training by Program Director and/or Clinical Supervisor on documentation requirements within 14 days of hire. Refresher training on documentation requirements will be held for all staff on a yearly basis, with the next training being held in May 2022. |
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 ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in four of four applicable records reviewed.
Client #1 was admitted on January 28, 2021 and discharged on February 23, 2021. The client record did not contain documentation of follow-up information.
Client #4 was admitted on October 2, 2014 and was discharged on October 12, 2021. The client record did not contain documentation of follow-up information.
Client #5 was admitted on January 9, 2015 and discharged on May 5, 2021. The client record did not contain documentation of follow-up information.
Client #7 was admitted on April 15, 2021 and was discharged on September 23, 2021. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/28/22, THW Program Director and Clinical Supervisor held a staff meeting and refresher training about accuracy, detail, timely submission, and requirements for forms and documents. This training discussed discharge procedures and documentation, including follow up documentation. All new staff will be training by Program Director and/or Clinical Supervisor on documentation requirements within 14 days of hire. Refresher training on documentation requirements will be held for all staff on a yearly basis, with the next training being held in May 2022. |