INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 13-15, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Lebanon Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
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
Personnel records were reviewed on September 13-15, 2016.
Employee # 5 was hired as a counselor on 1/4/16. The qualifications documented in the employee's record indicated that the employee completed an Associates degree in Psychology. The employee's record also documented 8 months of clinical experience in a health or human service agency. Therefore, Employee #4 did not meet the qualifications for the position of counselor.
Employee # 7 was hired as a counselor on 11/24/15. The qualifications documented in the employee's record indicated that the employee completed a a Bachelors degree in History, and a Masters of Divinity degree. The employee's record also documented 10 months of clinical experience in a health or human service agency. Therefore, Employee # 7 did not meet the qualifications for the position of counselor.
Employee # 8 was hired as a counselor on 5/2/16. The qualifications documented in the employee's record indicated that the employee completed a Bachelors degree in Clinical Psychology. The employee's record also documented 4 months of clinical experience in a health or human service agency. Therefore, Employee # 8 did not meet the qualifications for the position of counselor.
These findings was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Program has accepted the Departments position of the Counselors in question not meeting the qualifications for counselors. The decision was rendered in a letter dated September 18, 2016 from the Department. The 3 employees, #4,#5,#7 have all been reclassified as Counselor Assistants and caseloads and Clinical Supervision hours have been adjusted to reflect the status change. Training plans have also been developed to assist the individuals in question in becoming Counselors under the Departments set criteria. In future hiring the program will make sure all candidates meet the set criteria for position of Counselor. |
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Personnel records were reviewed on September 13-15, 2016. The facility failed to consistently document required direct observation and close supervision of employee # 9.
Employee # 9 was hired as a counselor assistant on 1/27/16. The qualifications documented in the employee's record indicated that the employee completed a HS diploma. The facility failed to document required weekly supervision for the following weeks: 3/27/16 - 4/2/16, 4/24/16 - 4/30/16, and 5/29/16 - 6/16/16.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinical Supervisor will develop a supervision schedule, post and share with Counselors and Counselor Assistants with weekly dates and times of supervision meetings. Clinical Supervisor will document and maintain a log of all supervisions and keep a copy of the individual supervision notes in an independent file for retrieval. This log will be reviewed by Clinic Director weekly during Management Meetings. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Twelve client records were reviewed on September 13-15, 2016. The facility failed to document that the client had been notified, in writing, of decision to terminate the client's treatment in client record # 6.
Client # 6 was admitted into treatment on 4/11/12 and was involuntarily terminated from treatment on 9/21/15. The client's record failed to document that the client received written notification of the facility's decision to terminate the client's treatment.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All Patients will receive a letter of Involuntary Termination from Treatment prior to being discharged from treatment. All termination letters will be generated by the Clinic Director after approval from medical and clinical team to terminate treatment. The Clinical Supervisor will develop a tracking tool/checklist to use for all clients Involuntary Termination from Treatment Letters and counselors will place copy in client record. Patient record will be audited by Clinical Supervisor prior to discharge to insure patient has received a Letter of Involuntary Treatment Termination. If patient is not available to receive letter, a copy will be mailed to patient address on file notifying patient of Treatment Termination. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
|
Observations
Based on the review of administrative documentation regarding the methadone inspection, the facility failed to consistently provide narcotic treatment physician services at least one hour per week onsite, for every ten clients.
Physician time sheets for the time period of April 1, 2016 - July 30, 2016 were reviewed on September 15, 2016. The facility did not provide sufficient onsite physician hours for each week.
During the week of July 17, 2016, the averaged client census was 342. The facility was required to provide at least 34.2 physician hours. There were 31 onsite physician hours documented. The amount of onsite physician hours documented did not meet the required hours.
During the week of July 24, 2016, the averaged client census was 344. The facility was required to provide at least 34.4 physician hours. There were 33 onsite physician hours documented. The amount of onsite physician hours documented did not meet the required hours.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinic Director will have Census reported to Medical Director weekly at Medical staff meeting.
Medical Director will determine the number of physician service hours needed and adjust schedules to meet patient needs.
Census will be recorded in the staff meeting minutes weekly for compliance with regulation 715.6 Physician staffing. Clinic Director will review and monitor all schedules for the Medical team weekly in accordance to the required hours needed to comply with the regulation.
|
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
|
Observations
Based on the review of administrative documentation regarding the methadone inspection, the facility failed to consistently ensure that one-third of all required narcotic treatment physician time was provided by a narcotic treatment physician.
Physician time sheets for the time period of April 1, 2016 - July 30, 2016 were reviewed on September 15, 2016. The narcotic treatment physician did not provide one-third of all required narcotic treatment time for each week.
During the week of July 17, 2016, the facility provided 31 onsite physician hours, completed by the narcotic treatment physician, physician assistant, and certified registered nurse practitioner. The narcotic treatment physician was required to provide 11.40 physician hours and 6 hours were documented for the narcotic treatment physician. The amount of onsite physician hours documented for the narcotic treatment physician did not meet the required hours.
During the week of July 24, 2016, the facility provided 33 onsite physician hours, completed by the narcotic treatment physician and certified registered nurse practitioner. The narcotic treatment physician was required to provide 11 physician hours and 8 hours were documented for the narcotic treatment physician. The amount of onsite physician hours documented for the narcotic treatment physician did not meet the required hours.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Medical Director will determine the number of physician service hours needed for compliance with regulation 715.6 Physician staffing
Medical Director will adjust his working schedule to provide one-third of needed
Physician treatment time as required by 715.6(e)
Medical Director will then delegate the remaining physician treatment hours to
the Physician assistant and/or certified registered nurse practitioner.
Clinic Director will approve and monitor all schedules for Medical staff to insure compliance with regulations
|
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
|
Observations
Twelve client records were reviewed on September 13-15, 2016. The facility failed to document a photograph of the client that included the client's name and birth date in client records # 3 and 10.
Client # 3 was admitted into treatment on 5/11/16 and was still active in treatment at the time of the inspection. The client's record did not document a photograph that included the client's name and birth date.
Client # 10 was admitted into treatment on 7/11/16 and was still active in treatment at the time of the inspection . The client's record did not document a photograph that included the client's name and birth date.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Patient photo ID's which includes the patient's legal name and date of birth will be copied at the time of intake for all patients. A copy of the Photo ID will remain with the patient record. The Clinical Supervisor will develop a new admission tracking tool and will review checklist with all patients prior to admission for all of the required documents which include the Photo ID. The Programs Administrative team will develop a list of all patients due and record a copy of the new Photo ID every 3 years. Both patient #3 and # 10 have Photo ID's placed in their patient records since the inspection. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Twelve client records were reviewed on September 13-15, 2016. The facility failed to provide 2.5 hours of psychotherapy per month in client records # 1, 2, and 3.
Client # 1 was admitted into treatment on 3/12/15 and was still active in treatment at the time of the inspection. The client's record documented an average of 1.156 hours of psychotherapy per month.
Client # 2 was admitted into treatment on 11/5/15 and was still active in treatment at the time of the inspection. The client's record documented an average of 1.1 hours of psychotherapy per month.
Client # 3 was admitted into treatment on 5/11/16 and was still active at the time of the inspection. The client's record documented an average of 1.4 hours of psychotherapy per month.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All patients that have been in the program for less than 2 years will complete the require counseling time. This will be evidenced by the Clinical Supervisor developing a master list of patients counseling hours, and documenting contact log in patient record reviewing progress notes bi-weekly to assure compliance |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Twelve client records were reviewed on September 13-15, 2016. In client records # 8 and 12, the facility failed to provide documentation verifying that the following patient files were transferred to the receiving narcotic treatment program: admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.
Client # 8 was admitted into treatment on 11/3/14 and documentation in the client's record indicated that the client transferred to another narcotic treatment program. The client's record failed to indicate that the required patient files were transferred to the receiving narcotic treatment program.
Client # 12 was admitted into treatment on 9/5/13 and transferred to another narcotic treatment program on 2/1/16. The client's record failed to indicate that the required patient files were transferred to the receiving narcotic treatment program.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Procedure:
Out-going: Maintenance patients requesting a permanent transfer to another treatment program will notify the primary counselor, allowing sufficient time to coordinate the request.
The program physician will review and document transfer request. The primary counselor will document attempt to confirm admission of the patient to the new treatment program in order to close patient record.
This will be monitored and by the by the Nursing and Clinical Supervisor within 7 days. Noncompliance will be addressed on an individual basis by Clinic Director.
|
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Twelve client records were reviewed on September 13-15, 2016. In client records # 3 and 10, the facility failed to document in writing that it notified a transferring narcotic treatment program of the client's admission and the date of the initial dose given to the client.
Client # 3 was admitted into treatment on 5/11/16, after transferring from another narcotic treatment program. The client was still active in treatment at the time of the inspection. The client's record did not contain written documentation that the facility notified the transferring narcotic treatment program of the client's admission and the date of the initial dose given to the client.
Client # 10 was admitted into treatment on 7/11/16, after transferring from another narcotic treatment program. The client was still active in treatment at the time of the inspection. The client's record did not contain written documentation that the facility notified the transferring narcotic treatment program of the client's admission and the date of the initial dose given to the client.
These findings were reviewd with facility staff during the licensing inspection.
|
Plan of Correction
In-coming patients: Maintenance patient requesting permanent transfer to another program will be required to provide the following information
1. Name and location of transferring program
2. Valid picture identification
3. Date of admission to transferring Program/date of consecutive treatment
4. Medication and medication level
5. Step level (if applicable)
6. Date and result of most recent tuberculin skin test result
7. Date and result of most recent RPR, including any necessary subsequent laboratory testing.
8. 3 months of urine screens
9. Discharge summary
Upon receipt of the above, patient will begin admission process. Prior to administering the first day of medication, the Dispensing Nurse will confirm (telephonically) last dosing date from the transferring CTC program and acceptance of patient to the CTC maintenance program. Assigned counselor will document record of transfer in the patient record. This will be tracked monthly by the Clinical Supervisor.
|
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.
|
Observations
Twelve client records were reviewed on September 13-15, 2016. The facility failed to document an annual physical examination in client record # 1.
Client # 1 was admitted into treatment on 3/12/15 and was active in treatment at the time of the inspection. The client's initial intake physical examination was completed on 3/10/15, and an annual physical examination was due to be completed by 3/10/16. The results of an annual physical examination were not documented in the client's record.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The clinic failed to provide an annual physical to client #1 as per 715.23(b)(5) due to client being incarcerated.
Annual Physical was completed 9/28/16.
To ensure that this does not happen again the following plan will be implemented:
If Client not discharged from program at time of incarceration, upon return to Clinic, client will be seen by medical provider.
Provider will document client's return to treatment from incarceration and any
change in medical condition or medication. If needed a new physical exam will be completed or if yearly exam is due it will be completed by the appropriate medical staff.
Client's charts will be reviewed by medical provider monthly to insure compliance with
715.23(b)(5)
|
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.
|
Observations
Twelve client records were reviewed on September 13-15, 2016. The facility failed to document a complete Biopsychosocial assessment during the intake process for client records # 1, 3, 7, and 11.
Client # 1 was admitted into treatment on 3/12/15 and is still active in treatment. The Biopsychosocial assessment documented in the client's record was completed on 4/22/15.
Client # 3 was admitted into treatment on 5/11/16 and is still active in treatment. The Biopsychosocial assessment documented in the client's record was completed on 9/1/16.
Client # 7 was admitted into treatment on 12/10/15 and was discharged on 5/25/16. The Biopsychosocial assessment documented in the client's record was completed on 3/29/16.
Client # 11 was admitted into treatment on 2/29/16 and was still active in treatment. The Biopsychosocial assessment documented in the client's record was completed on 5/3/16.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinical Supervisor will develop a chart to document when all Bio psychosocial Assessments are due and will monitors counselors progress. All patient demographics will be entered by the Clinical Supervisor at the time of patient orientation to the program. All Bio psychosocial Assessments will be forwarded to the counselor to be assigned the patient by the Clinical Supervisor along with a due date for completion.
Upon completion, all Bio psychosocial will be returned to the Clinical Supervisor for review within 15 days of admission.
Comprehensive Treatment Plan will be developed and submitted for signatures within the first 30 days of admission a required.
|
709.92(a) 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:
|
Observations
Twelve client records were reviewed on September 13-15, 2016. The facility failed to to document a comprehensive treatment plan in client records # 3, 7, and 11. The facility also failed to documented a comprehensive treatment plan during the specified timeframe for client record # 10.
Client # 3 was admitted into treatment on 5/11/16 and was still active in treatment. The preliminary treatment plan documented in the client's was completed on 5/10/16. A comprehensive treatment plan was not documented n the client's record.
Client # 7 was admitted into treatment on 12/10/15 and was discharged on 5/25/16. The preliminary treatment plan documented in the client's record was completed on 12/17/15. A comprehensive treatment plan was documented in the client's record.
Client # 10 was admitted into treatment on 7/11/16 and was still active in treatment. The preliminary treatment documented in the client's record was completed on 7/8/16. The comprehensive treatment plan documented in the client's record was completed on 8/26/16.
Client # 11 was admitted into treatment on 2/29/16 and was still active in treatment. The preliminary treatment plan documented in the client's record was completed on 2/25/16. A comprehensive treatment plan was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Patients who are currently active in treatment will have comprehensive treatment plans developed by November 1, 2016. Clinical Supervisor will meet with counselors weekly during scheduled supervision sessions and review status of treatment plans. Newly admitted patients will receive comprehensive treatment plans within the first 30 days of treatment. Clinical Supervisor will monitor for compliance. |
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.
|
Observations
Twelve client records were reviewed on September 13-15, 2016. The facility failed to document a treatment plan update at least every 60 days for client records # 1, 2, 5, 9, 11, and 12.
Client # 1 was admitted into treatment on 3/12/15 and was still active in treatment. A treatment plan update documented in the client's record was completed on 11/18/15. The subsequent treatment plan update was completed on 1/21/16. Another treatment plan update documented in the client's record was completed on 7/5/16. The subsequent treatment plan update was completed on 9/9/16.
Client # 2 was admitted into treatment on 11/5/15 and was still active in treatment. A treatment plan update documented in the client's record was completed on 1/8/16. The subsequent treatment plan update was completed on 4/1/16. Another treatment plan update documented in the client's record was completed on 5/9/16. The subsequent treatment plan update was completed on 7/11/16.
Client # 5 was admitted into treatment on 9/13/12 and was still active in treatment. A treatment plan update documented in the client's record was completed on 3/14/16. The subsequent treatment plan update was completed on 6/3/16. The following treatment plan update was completed on 8/30/16.
Client # 9 was admitted into treatment 1/6/10 and was still active in treatment. A treatment plan update documented in the client's record was completed on 11/12/15. The subsequent treatment plan update was completed on 1/28/16
Client # 11 was admitted into treatment on 2/29/16 and was still active in treatment. A treatment plan update documented in the client's record was completed on 6/17/16. The subsequent treatment plan update was due to be completed by 8/17/16 and it was not documented in the client's record.
Client # 12 was admitted into treatment on 9/5/13 and was discharged on 2/15/16. A treatment plan update documented in the client's record was completed on 11/3/15. The subsequent treatment plan update was completed on 1/18/16.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Patients who are currently active in treatment will have comprehensive treatment plans updated by November 1, 2016. Comprehensive treatment plans will be updated every 60 days according to regulations. Clinical Supervisor will meet with counselors weekly during scheduled supervision sessions and review status of treatment plans. Clinical Supervisor will develop a master list and monitor for compliance. |
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:
|
Observations
Twelve client records were reviewed on September 13-15, 2016. The facility failed to document a complete client record in client records # 2, 6, 10, 11, 12.
Client # 2 was admitted into treatment on 11/5/15 and was still active in treatment. The client's record of service documented a duplicate entry for a 90 minute group counseling session conducted on 7/9/16.
Client # 6 was admitted into treatment on 4/11/12 and was discharged on 9/21/15. The discharge summary documented in the client's record did not specify the type of discharge or reason for discharge.
Client # 10 was admitted into treatment on 7/11/16 and was still active in treatment. A progress note documented in the client's record indicated that that the client attended a group counseling session on 7/11/16. This group counseling session was not documented on the client's record of service.
Client # 11 was admitted into treatment on 2/29/16 and was still still active in treatment. The record of service documented in the client's record indicated that the client attended a group counseling session on 7/26/16. A progress note for this group counseling session was not documented in the client's record.
Client # 12 was admitted into treatment on 9/5/13 and was discharged on 2/15/16. A progress note documented in the client's record indicated that the client attended a group counseling session on 12/26/15. This group counseling session was not documented on the client's record of service.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All Documentation will be reviewed by Clinical Supervisor daily. Counselors will update log of service at completion of each session. Discharge summaries will be reviewed by clinical supervisor prior to submission. Clinical supervisor has developed a log to track all discharges and will review all records during monthly chart reviews. |