INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 5-6, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Berks Counseling Center Inc., was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
|
Observations
Based on a review of personnel records, the clinical supervisor failed to complete a core curriculum training in clinical supervision. The findings include: Sixteen personnel records were reviewed on March 5, 2013. Three of the sixteen were reviewed under the title of clinical supervisors, #4, 5 and 6. Personnel record #6 was hired by the facility on May 21, 2011 as a counselor and promoted on April 1, 2012. As of the date of the personnel record review on March 5, 2013 and the date of the conversation with the clinical director on March 6, 2013, the personnel record #6 failed to complete a core curriculum training in clinical supervision.
|
Plan of Correction
The clinical supervisor, identified as Personnel record #6, will complete the DDAP clinical supervisor core curriculum training by June 15, 2013 .
Moving forward, Human Resources and Clinical Director will ensure that all employees hired or promoted to the position of clinical supervisor will have met the requirements of regulation 704.6 of sections (a),(b),(c),(d),(e).
Please note: Clinical supervisor identified as personnel record #6, was hired by agency on 5/21/2007, not 5/21/2011.
|
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.
|
Observations
Based on the review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in one of ten record reviewed.Findings:Sixteen personnel records were reviewed on March 5, 2013. In personnel record #13, the counselor did not meet the qualifications for the position of counselor based on not having one year clinical experience prior to being hired. A interview with the clinical director on March 5, 2013 confirmed the findings.
|
Plan of Correction
Clinical director will assure all new counselors hired meet the DDAP qualifications for the position they were hired. If they do not meet the qualifications for a counselor, they can be brought on as a counselor assistant and provided with necessary supervision as per regulation. All current counselors will be in full compliance by June 1, 2013.
s.evans |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel and training records, the facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in five of sixteen personnel records. The findings include:Sixteen personnel records were reviewed on March 5, 2013. Eleven personnel records required documentation of HIV/AIDS and/or tuberculosis, sexually transmitted diseases and other health related topics training. Employee records # 4, 11, 13, 17 and 18 did not include documentation of the completion of the required training. Employee # 4 was hired on November 6, 2007. HIV/AIDS and TB/STD was due to be completed by November 6, 2008. There was no documentation that the employee had completed the HIV/AIDS, TB/STD training as of March 5, 2013. Employee # 11 was hired on March 31, 2008. HIV/AIDS and TB/STD was due to be completed by March 31, 2009. There was no documentation that the employee had completed the HIV/AIDS training as of March 5, 2013. Employee # 13 was hired on January 3, 2012. HIV/AIDS and TB/STD was due to be completed by January 3, 2013. There was no documentation that the employee had completed the HIV/AIDS training as of March 5, 2013. Employee # 17 was hired on September 16, 2009. HIV/AIDS and TB/STD was due to be completed by September 16, 2010. There was no documentation that the employee had completed the HIV/AIDS, TB/STD training as of March 5, 2013. Employee # 18 was hired on August 23, 2010. HIV/AIDS and TB/STD was due to be completed by August 23, 2011. There was no documentation that the employee had completed the HIV/AIDS, TB/STD training as of March 5, 2013. An interview with the clinical director on March 5, 2013 confirmed the findings.
|
Plan of Correction
Human Resource Specialist will assume responsibility for ensuring that all department supervisors ensure their staff persons and volunteers receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment. Compliance with this regulation for new hired staff is effective immediately.
BCC nurse will offer an additional 2 hour in house training on HIV/Aids for those staff that originally received 4 hours for this approved in house training.
Those employees here a year or more, who are not within the required time frame for receiving 6 hour HIV/Aids training and 4 hours STD/TB training will complete these trainings by June 30, 2013.
|
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the fire drill record, the facility failed to prepare alternate exit routes to be used during fire drills.The findings include:The fire drill records were reviewed on March 5, 2013. The fire drills were conducted from March 2012- February 2013. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility only documented all designated routes used during the fire drills. It was unable to be determined if alternating exits were used.An interview with the clinical director was conducted on March 5, 2013 confirmed the findings.
|
Plan of Correction
Berks Counseling Center's Health and Safety committee, facilitated by BCC office manager, has assumed responsibility for conducting monthly fire and disaster drills. They will prepare alternate exit routes to be used during fire drills as per regulation and document the alternate exit route utilized on each drill form. This is in effect immediately . |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills were conducted during different times of the day.The findings include:The fire drill record was reviewed on March 5, 2013. Twelve months of fire drills were reviewed, March 2012-February 2013. The facility's hours of operation are from Monday-Friday 9 am until 9 pm and Saturday 9 am to 4:30 pm. One fire drill documented at 2 pm, another documented at 11 am and the remaining were documented as occurring around 9 am. There were no evening drills documented. An interview with the clinical director on March 5, 2013 confirmed the findings.
|
Plan of Correction
Berks Counseling Centers Health and Safety committee, facilitated by BCC office manager, has assumed responsibility for conducting monthly fire and disaster drills. The committee will ensure that fire and disaster drills will be conducted on different days of the week, at different times of the day and on different staffing shifts. This will be in compliance effective immediately.
s.evans |
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.
|
Observations
Based on a review of the fire drill record, the facility failed to show documentation that the fire alarm system has been inspected annually.The findings include:The fire drill record was reviewed on March 5, 2013 and the exception letter was reviewed on March 6, 2013. The facility is to show documentation that the fire alarm system is in working order annually due to them not having the set off the alarm during fire drills. An interview with the clinical director on March 6, 2013 confirmed the findings.
|
Plan of Correction
BCC Office Manager and Health and Safety Committee have contacted the owner of the 645 Penn St. building, requesting current dated documentation that the fire alarm system is in working order annually since BCC does not have to set off the building alarm during fire drills. Such a document was submitted at time of audit but was not dated. BCC already possess an exception letter which allows us to perform fire drills for just our office using our phone intercom system. A current dated document stating the building fire alarm system was reviewed this year and annually going forward will be submitted to BCC by June 1, 2013.
s.evans |
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
|
Observations
Based on a review of facility documentation, the facility failed to complete an annual report for the fiscal year of July 1, 2011 to June 30, 2012.The findings included:The July 1, 2011 to June 30, 2012 annual report was reviewed on March 5, 2013. The annual report is to include a statement disclosing names of officers, directors and principal shareholders. The facility failed to include this on their July 1, 2011 to June 30, 2012 annual report.An interview with the project director and clinical director on March 6, 2013 confirmed the findings.
|
Plan of Correction
Please note that the list of board of directors for the fiscal year of 2011-2012 was included in the hard copy of the annual report at the time of inspection but was pulled out as a separate document for review. Clinical Director ensured that the list of Board of Directors document was returned to the hard copy of the 2011-2012 annual report effective immediately.
Berks Counseling Center Executive Director and Office manager will continue to ensure that a statement disclosing names of officers, directors and principal shareholders will be included in all annual reports going forward.
|
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical or psychiatric coverage.The findings include:The letters of agreement were reviewed on March 5, 2013. There were two letters of agreements for hospital or psychiatric coverage. The first hospital agreement was not updated and last signed by both parties on Aril 9, 2007. The second hospital agreement was dated for January 1, 2012 but did not state that the hospital had a 24 hour emergency psychiatric or emergency medical coverage. There was no other documentation of a 24- hour emergency medical coverage or psychiatric coverage agreement.An interview with the clinical supervisor on March 6, 2013 confirmed the findings.
|
Plan of Correction
This agency has secured a letter of agreement from a licensed hospital for 24 hour medical and psychiatric coverage. This letter was generated by the hospital's legal entity and is the extent of control that this agency has in the development of such letter of agreement. The hospital has an emergency department that is open 24 hours, 3365 days a year, for both medical and psychiatric emergency service and is a given that this service is open to anyone in need .
The current folder of letters of agreement will be reviewed by office manager and those that are no longer valid will be removed. Effective immediately.
s.evans
|
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based on a review of administrative policies and procedures, the facility failed to complete the 2011-2012 audit by the end of the project's fiscal year, as required by regulation.The findings include:The administrative policies and procedures were reviewed on March 5, 2013. Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year is from July through June. The project's audit for July 1, 2011 through June 30, 2012 was due to be completed no later than December 31, 2012. The audit for the July 1, 2011 through June 30, 2012 was completed on January 3, 2013. An interview with the project director and clinical director on March 6, 2013 confirmed the findings.
|
Plan of Correction
Berks Counseling Center obtains the services of an independent public accountant who completes their annual audit of financial activities associated with the project's drug/alcohol abuse services. . Relating to the accountant that we were in need of the written audit for review by December 31, 2012 was the extent of control BCC had in ensuring the report be completed by that date.
Going forward, BCC will continue to attempt to ensure that the accountant have the annual audit of BCC's financial activities, for each fiscal year, be completed before the due date cited in regulation 709.25. This is effective immediately.
s.evans |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on the review of client records, the facility failed to obtained informed and voluntary consents in eleven of sixteen client records.Findings:Sixteen client records were reviewed on March 6, 2013. Of the sixteen records, eleven records did not include documentation of the purpose of the release or denied the client's right to revoke their consent. Client #1 was admitted on December 3, 21012. A consent dated December 3, 2012 for emergency contact did not document what was being released to the family.Client #2 was admitted on October 19, 2012. A consent dated October 19, 2012 for an agency did not include documentation regarding what information was being released.Client #4 was admitted on February 11, 2013. A consent dated January 28, 2013 for an agency did not include documentation regarding what information was being released.Client #5 was admitted on December 5, 2012. A consent dated December 5, 2012 did not document the purpose for the release. Consent dated December 5, 2012 did not give the client the right to revoke their consent. What was documented on the consent form was "cannot be revoked by client until there has been a formal and effective termination by the supervisor".Client #6 was admitted on November 28, 2012. A consent dated November 28, 2012 did not document the purpose for the release. Consent dated November 28, 2012 did not give the client the right to revoke their consent. What was documented on the consent form was "cannot be revoked by client until there has been a formal and effective termination by the supervisor".Client #7 was admitted on October 16, 2012. A consent dated October 16, 2012 did not document the purpose for the release. Consent dated October 16, 2012 did not give the client the right to revoke their consent. What was documented on the consent form was "cannot be revoked by client until there has been a formal and effective termination by the supervisor".Client #8 was admitted on November 19, 2012. Consent dated October 16, 2012 did not give the client the right to revoke their consent. What was documented on the consent form was "cannot be revoked by client until there has been a formal and effective termination of my supervisor". A letter was sent out on November 20, 2012 to a government agency, but there was no consent to release for this agency.Client #9 was admitted on December 19, 2012 and discharged on January 25, 2013. A consent dated October 16, 2012 did not document the purpose for the release. Client #10 was admitted on September 12, 2012. Consent dated September 12, 2012 did not give the client the right to revoke their consent. What was documented on the consent form was "cannot be revoked by client until there has been a formal and effective termination of my supervisor". Client #11 was admitted on November 2, 2012 and discharged on December 24, 2012. A consent dated November 2, 2012 did not document the purpose for the release. Client #12 was admitted on June 14, 2012 and discharged on November 9, 2012. Consent dated September 11, 2012 did not give the client the right to revoke their consent. What was documented on the consent form was "cannot be revoked by client until there has been a formal and effective termination of my supervisor". A discussion with the clinical director on March 8, 2013 did not dispute the findings..
|
Plan of Correction
The consents that were cited are completed by agency Intake Specialist/Support Staff who are under the supervision of the Operations Coordinator. A training to review the policy and procedure of completing consent /authorization forms will be held on April 12, 2013 during the department's weekly team meeting and will be facilitated by the Operations Coordinator.
Currently, a member of the support staff checks that all consents are filled out correctly and completely at the end of each day. Beginning April 5, 2013, the Operations Coordinator will be double checking the consents as a form of quality control. This additional quality control check will be implemented for 3
- Please note ? Clinical director and clinical supervisors conducted a formal review of the findings of the auditor of regulation #0277 and found 1 error in her findings. In client record #8 the consent for the client's Probation Officer was present in the electronic record where she had stated it was missing at time of inspection.
s.evans |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in eleven of sixteen client records. The findings include:Sixteen client records were reviewed on March 6, 2013. All records were reviewed for psychosocial evaluations.The psychosocial evaluations in client records # 7, 10 and 11 did not include an evaluation of the client's problems/needs and how they would impact treatment. The psychosocial evaluations in client records #2, 3, 4, 7, 8, 10, 11 and 12 did not include an evaluation of the client's assets/strengths and how they would impact treatment. The psychosocial evaluations in client records #2, 4, 7, 10, 11 and 12 did not include an evaluation of the client's support systems and how they would relate to treatment. The psychosocial evaluations in client records #2, 3, 4, 7, 10, 11 and 12 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment. The psychosocial evaluations in client records #2, 3, 4, 7, 11 and 12 did not include an evaluation of the client's negative factors and how they would impact treatment. The psychosocial evaluations in client records #2, 3, 4, 7, 8, 10 and 11 did not include an evaluation of the counselor conclusions/impressions of the client. Also, per the facility policy, psychosocial evaluations will be completed within 15 days after the clients intake. Client records #1, 5, 6 did not documented psychosocial evaluations.Client #1 was admitted on December 3, 2012. The psychosocial evaluation should have been completed by December 18, 2012. At the time of the inspection, there was no documentation of client #1's psychosocial evaluation.Client #5 was admitted on December 5, 2012. The psychosocial evaluation should have been completed by December 20, 2012. At the time of the inspection, there was no documentation of client #2's psychosocial evaluation.Client #6 was admitted on November 28, 2012. The psychosocial evaluation should have been completed by December 13, 2012. At the time of the inspection, there was no documentation of client #1's psychosocial evaluation.An interview with the clinical director on March 8, 2013 confirmed the findings.
|
Plan of Correction
Each individual therapist, designated with this deficiency during the audit, will be addressed during individual supervision with their direct clinical supervisor regarding the policy and procedure of completing a Psychosocial Evaluation and will review all their cases for Psycho social Evaluations that do not include assets/strengths, support systems, coping mechanisms, evaluation of the client problems/needs/negative factors and how they would impact treatment of the client and counselors conclusions/impressions of the client as well as missing Psychosocial Evaluations. This process will be implemented in the counselors' weekly supervision beginning on April 8, 2013.
Clinical Supervisors will continue to monitor for completion of Psychosocial Evaluations that meet regulatory standards during all counselors' weekly individual counselor supervision.
Clinical director will monitor for compliance to this standard via monthly random record reviews.
BCC's QA (Quality Assurance) Committee will continue to monitor for compliance to this standard as well.
Effective immediately.
|
709.93(a)(3) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
|
Observations
Based on a review of client records, the facility failed to provide a record of service in sixteen of sixteen records reviewed.The findings include:Sixteen client records were reviewed on March 6, 2013. The facility failed to have available record of service documentation in all records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16.An interview with the clinical director on March 6, 2013 confirmed the findings.
|
Plan of Correction
The EHR (electronic health record) that we utilize does have the ability to produce a record of service that chronologically lists all services rendered for each individual client at BCC. It is an application that is generated through the report function of the program. It can be brought up on screen and also printed as a hard copy. This record of service is available for every client currently in treatment as well as those inactive at this time. Going forward, this document will be made available, either on screen or printed as a hard copy for all client records selected for review. This function was available at time of inspection, is currently available and continues to be avaialble. |
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.
|
Observations
Based on a review of client records, the facility failed to document a case consultation within the 90 day time frame established by the facility in two of seven client records.The findings include:Sixteen client records were reviewed on March 6, 2013. Seven of the sixteen were required to document case consults, #1, 2, 3, 6, 7, 8 and 12. Per agency policy, case consultations shall be completed quarterly. The facility did not document case consultations in client records, #1, 3 and 6. .Client # 3 was admitted on October 25, 2012. The case consultation was due by January 25, 2013. At the time of the inspection the case consultation was not documented in client #3's record. Client # 6 was admitted on November 28, 2012. The case consultation was due by December 28, 2012. At the time of the inspection the case consultation was not documented in client # 6's record.
|
Plan of Correction
A new system of tracking required documentation, which includes case reviews was developed and is being implemented on April 11, 2013 during clinical team group supervision following training on the use of this new tracking system. The system focuses on the document being completed and within the required time frame. This system is being required of all counselors so as to promote consistency of compliance across the entire clinical team.
Clinical Supervisors and Clinical Director will facilitate the training.
Clinical Supervisors will monitor for use of required documentation grid during all counselors' weekly individual counselor supervision, with detailed supervision given to counselor responsible for identified deficiencies.
Clinical Director will monitor for compliance to this standard via monthly random record reviews.
BCC's QA (Quality Assurance) Committee will continue to monitor for compliance to this standard as well.
s.evans |
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.
|
Observations
Based on a review of client records, the facility failed to document follow-up attempts in four of eight client records. The findings include: Sixteen client records were reviewed on March 6, 2013. Per facility policy, follow-up attempts will take place 7 days for referrals and 30 days for all others. Eight of the sixteen client records were discharged client records, #9, 10, 11, 12, 13, 14, 15 and 16. Follow up was not documented in four client records, #10, 11, 12 and 15.Client #10 was admitted on September 12, 2012 and discharged on November 9, 2012. The follow-up attempt was due by December 9, 2012. As of the date of the licensing inspection client #10's follow-up was not documented. Client #11 was admitted on November 2, 2012 and discharged on December 24, 2012. The follow-up attempt was due by January 24, 2013. As of the date of the licensing inspection client #11's follow-up was not documented. Client #12 was admitted on June 14, 2012 and discharged on November 9, 2012. The follow-up attempt was due by December 9, 2012. As of the date of the licensing inspection client #12's follow-up was not documented. Client #15 was admitted on August 1, 2012 and discharged on September 17, 2012. The follow-up attempt was due by October 17, 2012. As of the date of the licensing inspection client #15's follow-up was not documented. An interview with the clinical director on March 8, 2013 confirmed the findings.
|
Plan of Correction
A new system of tracking and completing follow up information has been developed and will be implemented on April 11, 2013 following a training on the policy and procedure of completing follow ups and on the new system, during clinical team group supervision that same day. Clinical Supervisors and Clinical Director will facilitate the training.
Clinical Supervisors will monitor for use of above follow up system during all counselors' weekly individual counselor supervision.
Clinical director will monitor for compliance to this standard via monthly random record reviews.
BCC's QA (Quality Assurance) Committee will continue to monitor for compliance to this standard as well.
s.evans |