INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, GPHA Al-Assist Behavioral Health Care Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to document a mechanism to collect feedback on completed training in four of nine records.The findings include:Nine personnel records were reviewed on July 28, 2014. The following staff failed to have documented feedback forms after training ' s, #1, 2, 3 and 4. The training year reviewed was January 1, 2013 through December 31, 2013. The findings were discussed with facility staff on July 29, 2014.
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Plan of Correction
704.11 (a)(3) LICENSURE - Training Feedback
CORRECTIVE ACTION:
The findings of 2014 DDAP Licensure Renewal Inspection will be disseminated and reviewed with Chief Behavioral Health Officer, Quality Assurance Manager, Drug / Alcohol Program Coordinator, Coordinator of Behavioral Health Services at the next scheduled Management Meeting. The Quality Assurance Manager will identify any drug/alcohol treatment staff that lack evaluations of their annual trainings and direct them to complete those evaluations ASAP. The Quality Assurance Manager will develop / institute procedures ensuring that all staffs external and internal training certificates include attached evaluations prior to filing them into their training / personnel records. Any training certificates lacking an accompanying evaluation will not be accepted and withheld from staffs' training record until the evaluation is submitted. Also, the Quality Assurance Manager will randomly review personnel / training files to ensure compliance.
TIME FRAME FOR COMPLETION:
September 4, 2014
PERSONS RESPONSIBLE:
Quality Assurance Manager, Drug / Alcohol Program Coordinator, Coordinator of Behavioral Health Services
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of nine personnel records.The findings include:Nine personnel records were reviewed on July 28, 2014. Seven personnel record pertained to counselors who are required to obtain 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel records # 3 and 4. Training year reviewed was January 1, 2013 through December 31, 2013.Employee # 3 was hired on January 7, 2010. Employee # 3 had only 22.5 clock hours of training documented for the 2013 training year. Employee #4 was hired on November 1, 2010. Employee #4 had only 7.5 clock hours of training documented for the 2013 training year.The findings were discussed with facility staff on July 29, 2014.
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Plan of Correction
704.11(f)(2) LICENSURE -Training Hours Required for Counselors
CORRECTIVE ACTION:
The 2014 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with the Chief Behavioral Health Officer, Drug Alcohol Program Coordinator, Coordinator of Behavioral Health, and Quality Assurance Manager at the next scheduled Management Meeting. The Drug / Alcohol Coordinator, Quality Assurance Manager and Clinical Supervisors will ensure that all counseling staffs' Annual Training Plans include, at least, 25 clock hours of training relative to drug/alcohol treatment, and will monitor the completion of these mandatory training hours during weekly and/or bi-weekly supervision meetings. All staffs will receive written notice from the Quality Assurance Manager that failure to complete 25 clock hours of annual training will result in disciplinary action, and possible non-credentialed status with restricted counseling privileges.
TIME FRAME FOR COMPLETION:
September 1, 2014 - Ongoing Monitoring
PERSONS RESPONSIBLE:
Drug/Alcohol Program Coordinator, Quality Assurance Manager, Coordinator of Behavioral Health
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate the staff and client restrooms by an exhaust fan or window.The findings include:A physical plant inspection was conducted with facility staff on July 29, 2014 around 9:00 am. Per regulation, the nonresidential facility shall ventilate restrooms by exhaust fan or window. The facility has one staff restroom and one client restroom on the third floor and two restrooms on the second floor. The staff restroom on the third floor and the one client restroom on the second floor failed to have a window that could open and/or a working exhaust fan. The findings were discussed with facility staff on July 29, 2014 and they confirmed the findings.
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Plan of Correction
709.93(a) Licensure ? Bathrooms
CORRECTIVE ACTION:
The Drug /Alcohol Program Coordinator immediately informed the Maintenance Dept. of the dysfunctional exhaust fan in the 4th Floor Bathroom, and requested repair/replacement. During the interim period, the housekeeping staff will keep the window open for ventilation. The Drug/Alcohol Program Coordinator will follow-up to ensure that the repair is completed. Afterwards, the Security and House Keeping staff will make daily rounds to ensure that the exhaust fan continues to function properly.
TIME FRAME FOR COMPLETION:
August 25, 2014 ? Ongoing Monitoring
PERSONS RESPONSIBLE:
Drug/ Alcohol Program Coordinator, Maintenance Dept., Housekeeping and Security Staff.
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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:
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in six of ten records reviewed.The findings include:Ten client records were reviewed on July 29, 2014. The facility failed to document informed and voluntary consents in six client records, specifically records, #1, 3, 4, 5, 7 and 9.Client record #1 - contained a consent to release information form dated 3/3/14 to an insurance agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information and intake/admission information. Client record #3 contained a consent to release information form dated 12/6/13 to an insurance agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information and intake/admission information. Additionally, the following dated consent to release forms which failed to have documented whom the consent was for, but the client and staff signed and dated the consent forms. The following dates are 12/2/13 and 12/4/13.Client record #4 contained a consent to release information form dated 2/10/14 to an insurance agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information, intake/admission information, plan care/review, psychiatric evaluation, lab results, psychological assessment, strength assessment, progress notes, psychological evaluation/report, screening assessment, medication prescribed, medical history/physical history and discharge summary/plan. Client record #5 - contained a consent to release information form dated 2/25/14 to an insurance agency that exceeded 4 PA Code 255.5 by allowing the facility to release the following information: billing &/or insurance information and intake/admission information. Client record #7 contained a letter dated 2/10/14 which had identifying client information. The letter failed to have the name of the person/or agency and this licensing specialist could not determine if there was a consent to release on file. Client record #9 contained the following dated consent to release forms which failed to have documented whom the consent was for, but the client and staff signed and dated the consent forms. The following dates are 10/8/13 and 10/9/13.A discussion with the facility director took place on July 29, 2014.
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Plan of Correction
709.28(c) LICENSURE - Confidentiality
CORRECTIVE ACTION:
The 2014 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with the Chief Behavioral Health Officer, Quality Assurance Manager, Coordinator of Behavioral Health, and Drug/Alcohol Program Coordinator at the next scheduled Management Meeting. The Chief Behavioral Health Officer and Quality Assurance Manager will outline specific changes to be made to the EHR Consent to Release Confidential Information Form that will ensure compliance with regulations protecting the confidentiality of clients. These changes will be conveyed to EHR AVATAR Technical Support for immediate correction. The Chief Behavioral Health Officer and Quality Assurance Manager will review the corrected (revised) Consent to Release Confidential Information Form to ensure that the Consent to Release Confidential Information Form does not contain any information which exceeds 4 PA Code 255.5.
The Quality Assurance Manager and Quality Assurance Clerks will provide one (1) hour training to Drug/Alcohol Counselors specifically on completing the Consent to Release Confidential Information Form. Additionally, the Drug/Alcohol Program Coordinator, Clinical Supervisors, Quality Assurance Manager and Clerks will monitor client records weekly to ensure that all Consent to Release Confidential Information Forms are completed in accordance with 4 PA Code 255.5 regulations.
TIME FRAME FOR COMPLETION:
September 1, 2014- Ongoing Monitoring
PERSONS RESPONSIBLE:
Chief Behavioral Health Officer, Drug/Alcohol Program Coordinator, Quality Assurance Manager, and Coordinator of Behavioral Health Services.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a client history in three of ten client records.The findings include:Ten client records were reviewed on July 29, 2014. Ten client records required the documentation of a history. The facility failed to provide documentation of a client's history in client records # 6, 8 and 10.Client # 6 was admitted on January 17, 2014 and discharged on April 14, 2014. As of the date of client #6's discharge there was no documentation of the client's history.Client # 8 was admitted on March 20, 2014 and discharged on May 1, 2014. As of the date of client #8's discharge there was no documentation of the client's history.Client # 10 was admitted on December 18, 2013 and discharged on June 19, 2014. As of the date of client #10's discharge there was no documentation of the client's history.The findings were discussed with facility staff on July 29, 2014.
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Plan of Correction
709.91(b)(3)(i) LICENSURE ? Intake and Admission
CORRECTIVE ACTION:
The 2014 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with the Chief Behavioral Health Officer, Quality Assurance Manager, Coordinator of Behavioral Health, and Drug/Alcohol Program Coordinator at the next scheduled Management Meeting. The Drug/Alcohol Program Coordinator and Quality Assurance Manager will conduct mandated staff training on Intake, Admission and Assessment procedures. The training will cover the following specific areas:
- Documenting Client Histories
- Documenting Comprehensive Bio-Psychosocial Evaluations CBE)
- Developing Preliminary Treatment Plans
Additionally, the Quality Assurance Clerks, Clinical Supervisors, and Drug/Alcohol Program Coordinator will conduct daily / weekly random reviews to ensure that these clinical documents are included in the client records.
TIME FRAME FOR COMPLETION:
September 1, 2014- Ongoing Monitoring
PERSONS RESPONSIBLE:
Drug/Alcohol Program Coordinator, Quality Assurance Manager, and Quality Assurance Clerks
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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
Based on a review of client records, the facility failed to document a psychosocial evaluation in six of ten client records.The findings include:Ten client records were reviewed on July 29, 2014. Ten client records required the documentation of a psychosocial evaluation. The facility failed to provide documentation of a psychosocial evaluation in client records # 1, 6, 7, 8, 9 and 10.Client # 1 was admitted on March 13, 2014. As of the date of the licensing inspection there was no documentation of a psychosocial evaluation.Client # 6 was admitted on January 17, 2014 and discharged on April 14, 2014. As of the date of client #6's discharge there was no documentation of a psychosocial evaluation.Client # 7 was admitted on October 25, 2013 and discharged on April 28, 2014. As of the date of client #7's discharge there was no documentation of a psychosocial evaluation.Client # 8 was admitted on March 20, 2014 and discharged on May 1, 2014. As of the date of client #8's discharge there was no documentation of a psychosocial evaluation.Client # 9 was admitted on October 9, 2013 and discharged on December 20, 2014. As of the date of client #9's discharge there was no documentation of a psychosocial evaluation.Client # 10 was admitted on December 18, 2013 and discharged on June 19, 2014. As of the date of client #10's discharge there was no documentation of a psychosocial evaluation.The findings were discussed with facility staff on July 29, 2014.
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Plan of Correction
709.91(b)(6) LICENSURE ? Intake and Admission
CORRECTIVE ACTION:
The 2014 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with the Chief Behavioral Health Officer, Quality Assurance Manager, Coordinator of Behavioral Health, and Drug/Alcohol Program Coordinator at the next scheduled Management Meeting. The Drug/Alcohol Program Coordinator and Quality Assurance Manager will conduct mandated staff training on Intake, Admission and Assessment procedures. The training will cover the following specific areas:
- Documenting Client Histories
- Documenting Comprehensive Bio-Psychosocial Evaluations CBE)
- Developing Preliminary Treatment Plans
Additionally, the Quality Assurance Clerks, Clinical Supervisors, and Drug/Alcohol Program Coordinator will conduct daily / weekly random reviews to ensure that these clinical documents are included in the client records.
TIME FRAME FOR COMPLETION:
September 1, 2014- Ongoing Monitoring
PERSONS RESPONSIBLE:
Drug/Alcohol Program Coordinator, Quality Assurance Manager, and Quality Assurance Clerks
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan in three of ten client records.The findings include:Ten client records were reviewed on July 29, 2014. Ten client records required the documentation of a preliminary treatment plan. The facility failed to provide documentation of a preliminary treatment plan in client records # 4, 6, and 10.Client # 4 was admitted on January 30, 2014. As of the date of the licensing inspection there was no documentation of a preliminary treatment plan.Client # 6 was admitted on January 17, 2014 and discharged on April 14, 2014. As of the date of client #6's discharge there was no documentation of a preliminary treatment plan.Client # 10 was admitted on December 18, 2013 and discharged on June 19, 2014. As of the date of client #10's discharge there was no documentation of a preliminary treatment plan.The findings were discussed with facility staff on July 29, 2014.
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Plan of Correction
709.92(a)(2) LICENSURE ? Treatment and Rehabilitation Services
The 2013 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with the Chief Behavioral Health Officer, Quality Assurance Manager, Coordinator of Behavioral Health, and Drug/Alcohol Program Coordinator at the next scheduled Management Meeting. The Drug/Alcohol Program Coordinator and Quality Assurance Manager will conduct mandated staff training on developing Treatment Plans and Treatment Plan Up-Dates. The training will cover the following specific areas:
- Developing Preliminary Treatment Plans
- Developing Comprehensive Treatment Plans
- Developing Treatment Plan Up-Dates
- Documenting the type and frequency of treatment and rehabilitative services
- Documenting Proposed Support Services
Additionally, the Quality Assurance Clerks, Clinical Supervisors, and Drug/Alcohol Program Coordinator will conduct daily / weekly random reviews to ensure that these clinical documents are included in the client records.
TIME FRAME FOR COMPLETION:
September 12, 2014- Ongoing Monitoring
PERSONS RESPONSIBLE:
Drug/Alcohol Program Coordinator, Clinical Supervisors, Quality Assurance Manager, Quality Assurance Clerks
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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
Based on a review of client records, the facility failed to include the type and frequency of treatment and rehabilitation services in five of ten client records.The findings include:Ten client records were reviewed on July 29, 2014. Nine were reviewed for comprehensive treatment plans. Three of the nine records, #2, 4, 5, lacked documentation for the type and frequency of treatment and rehabilitation services on the client's treatment plan. Additionally, two of the nine records, #6 and 8, lacked the documentation for the frequency of treatment and rehabilitation services on the client's treatment plan. The findings were discussed with facility staff on July 29, 2014.
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Plan of Correction
709.92(a)(2) LICENSURE ? Treatment and Rehabilitation Services
CORRECTIVE ACTION:
The 2013 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with the Chief Behavioral Health Officer, Quality Assurance Manager, Coordinator of Behavioral Health, and Drug/Alcohol Program Coordinator at the next scheduled Management Meeting. The Drug/Alcohol Program Coordinator and Quality Assurance Manager will conduct mandated staff training on developing Treatment Plans and Treatment Plan Up-Dates. The training will cover the following specific areas:
- Developing Initial Treatment Plans
- Developing Comprehensive Treatment Plans
- Developing Treatment Plan Up-Dates
- Documenting the type and frequency of treatment and rehabilitative services
- Documenting Proposed Support Services
Additionally, the Quality Assurance Clerks, Clinical Supervisors, and Drug/Alcohol Program Coordinator will conduct daily / weekly random reviews to ensure that these clinical documents are included in the client records.
TIME FRAME FOR COMPLETION:
September 12, 2014- Ongoing Monitoring
PERSONS RESPONSIBLE:
Drug/Alcohol Program Coordinator, Clinical Supervisors Quality Assurance Manager, and Quality Assurance Clerks
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed support services specific to each client on the individual treatment and rehabilitation plan in three of ten records reviewed. The findings include:Ten client records were reviewed on July 29, 2014. Nine were reviewed for comprehensive treatment plans. Three of the nine records, #5, 8 and 10 lacked documentation of support services specific to each client on the individual treatment and rehabilitation plan. The findings were discussed with facility staff on July 29, 2014.
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Plan of Correction
709.92(a)(3) LICENSURE ? Treatment and Rehabilitation Services
CORRECTIVE ACTION:
The 2013 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with the Chief Behavioral Health Officer, Quality Assurance Manager, Coordinator of Behavioral Health, and Drug/Alcohol Program Coordinator at the next scheduled Management Meeting. The Drug/Alcohol Program Coordinator and Quality Assurance Manager will conduct mandated staff training on developing Treatment Plans and Treatment Plan-Up-Dates. The training will cover the following specific areas:
- Developing Initial Treatment Plans
- Developing Comprehensive Treatment Plans
- Developing Treatment Plan Up-Dates
- Documenting the type and frequency of treatment and rehabilitative services
- Documenting proposed Support Services
Additionally, the Quality Assurance Clerks, Clinical Supervisors, and Drug/Alcohol Program Coordinator will conduct daily / weekly random reviews to ensure that these clinical documents are included in the client records.
TIME FRAME FOR COMPLETION:
September 12, 2014- Ongoing Monitoring
PERSONS RESPONSIBLE:
Drug/Alcohol Program Coordinator, Clinical Supervisors Quality Assurance Manager, and Quality Assurance Clerks
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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 client records, the facility failed to document a treatment plan update in three of ten client records. The findings include: Ten client records were reviewed on July 29, 2014. Six client records were required to have a treatment plan update. The facility failed to document a treatment plan update in client records #1, 3 and 10.Client #1 was admitted on March 13, 2014. The comprehensive treatment plan was completed on April 28, 2014. A treatment plan update was due by June 28, 2014. As of the date of the licensing inspection, the facility failed to document a treatment plan update. Client #3 was admitted on December 2, 2013. The comprehensive treatment plan was completed on December 6, 2013. The treatment plan updates were completed on February 4, 2014, April 8, 2014 and July 7, 2014. Treatment plan update dated July 7, 2014 was documented late. Client #10 was admitted on December 18, 2013 and discharged June 19, 2014. The comprehensive treatment plan was completed on January 24, 2014. As of the date of client #10's discharge date, the facility failed to document any treatment plan updates.
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Plan of Correction
709.93(a) LICENSURE - Client Records
CORRECTIVE ACTION:
The 2013 DDAP Licensing Renewal Inspection findings will be disseminated and reviewed with the Chief Behavioral Health Officer, Quality Assurance Manager, Coordinator of Behavioral Health, and Drug/Alcohol Program Coordinator at the next scheduled Management Meeting. The Drug/Alcohol Program Coordinator and Quality Assurance Manager will conduct mandated staff training on Developing Treatment Plans and Treatment Plan Up-Dates. The training will cover the following specific areas:
- Developing Initial Treatment Plans
- Developing Comprehensive Treatment Plans
- Developing Treatment Plan Up-Dates
- Documenting the type and frequency of treatment and rehabilitative services
- Proposed Support Services
Additionally, the Quality Assurance Clerks, Clinical Supervisors, and Drug/Alcohol Program Coordinator will conduct daily / weekly random reviews to ensure that these clinical documents are included in the client records.
TIME FRAME FOR COMPLETION:
September 12, 2014- Ongoing Monitoring
PERSONS RESPONSIBLE:
Drug/Alcohol Program Coordinator, Clinical Supervisors Quality Assurance Manager, and Quality Assurance Clerks
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709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to have a complete record in seven of ten records reviewed.The findings include:Ten client records were reviewed on July 29, 2014. Seven client records failed to have a complete record, #1, 3, 4, 5, 7, 8 and 10.Client #1 was admitted on March 13, 2014. Client #1's case consultation was completed on June 3, 2014. The facility failed to document who all participated in the case consultation. The only person documented as being a part of the case consultation was client #1's counselor. Client #3 was admitted on December 2, 2013. Client #3's case consultations were completed on March 2, 2014 and June 31, 2014. The facility failed to document who all participated in the case consultation date June 31, 2014. The only person documented as being a part of the case consultation was client #3's counselor. Client #4 was admitted on January 30, 2014. Client #4's case consultation was completed on June 25, 2014. The facility failed to document who all participated in the case consultation. The only person documented as being a part of the case consultation was client #4's counselor. Client #5 was admitted on February 25, 2014. Client #5's case consultation was completed on May 23, 2014. The facility failed to document who all participated in the case consultation. The only person documented as being a part of the case consultation was client #5's counselor. Client #7 was admitted on October 25, 2013 and discharged on April 28, 2014. The facility failed to document a case consultation and discharge summary as of the date of the licensing inspection.Client #8 was admitted on March 20, 2014 and discharged on May 1, 2014. The facility failed to document progress notes as of the date of client #8's discharge date.Client #10 was admitted on December 18, 2013 and discharged on June 19, 2014. The facility failed to document a case consultation and discharge summary as of the date of the licensing inspection. Additionally, the facility only documented one progress note as of the date of the licensing inspection.The findings were discussed with facility staff on July 29, 2014.
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Plan of Correction
709.93(a) LICENSURE ? Client Records
709.93(a) Licensure ? Client Records
CORRECTIVE ACTION:
The DDAP Licensing Renewal Inspection findings will be disseminated and reviewed by the Clinical Management Team. The Chief Behavioral Health Officer and Quality Assurance Manager will consult with the EHR AVATAR Technical Support to request immediate correction to the signature program's routing mechanism to allow for more than one (1) signature on the Case Consultation Form. All clinical staff will receive an email informing them of the routing mechanism start-up date, which will allow primary counselors to obtain the electronic signatures of all case consultation participants. During the interim period, staff participating in case consultations will sign the "printed out" version of the form, which will be scanned into the client's record. With regard to missing Progress Notes and Discharge Summaries , the Drug /Alcohol Program Coordinator and Quality Assurance Manager will conduct targeted training to Counselors requiring re-training on developing and documenting Progress Notes, Discharge Summaries and Discharge Notes. Also, the Clinical Supervisors, Drug/Alcohol Program Manager, and Quality Assurance Clerks will conduct weekly / bi-weekly record reviews to ensure that Case Consultations, Discharge Summaries and Discharge Notes are completed correctly and entered into the client records. A special focus will be placed on ensuring that these identified Counselors have incorporated their training into effectively managing their client records.
TIME FRAME FOR COMPLETION:
September 19, 2014 ? Ongoing Monitoring
PERSONS RESPONSIBLE:
Chief Behavioral Health Officer, Coordinator of Behavioral Health Services, Quality Assurance Manager, Drug/ Alcohol Program Coordinator, Clinical Supervisors and Quality Assurance Clerks.
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