INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 24, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Penn Presbyterian Medical Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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711.17(a)(3) LICENSURE Subchapter B.Approval Procedures.Refusal or
711.17. Refusal or revocation.
(a) The Department may revoke or refuse to issue a certificate of compliance for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to complete follow-up information was submitted and approved by the Department for the June 27, 2024 and August 18, 2025 annual licensing inspections. Failing to complete follow up information was again found to be a deficiency in the June 24, 2026 annual licensing inspection.
A plan of correction for failing to obtain an informed and voluntary consent to release information form from the client prior to the disclosure of information was submitted and approved by the Department for the June 27, 2024 and August 18, 2025 annual licensing inspections. Failing to obtain an informed and voluntary consent to release information form from the client for the disclosure of information was again found to be a deficiency in the June 24, 2026 annual licensing inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
711.17(a)(3) LICENSURE
Subchapter B. Approval Procedures: Refusal or Revocation.
1. Leadership Oversight
On June 29, 2026, the Regulatory Director shared the preliminary DDAP survey results with senior leadership. The CEO designated the Vice President responsible for ambulatory addiction services to oversee implementation of corrective actions and ongoing compliance with approved plans of correction and DDAP regulations.
2. Root Cause Analysis and System Improvements
On June 30, 2026, the Regulatory Director reviewed the findings with an interdisciplinary team including Operations, Regulatory, Privacy, Information Services, and program leadership. Leadership determined that reliance on manual processes contributed to the repeat deficiencies and identified the need for system-level controls to support sustained compliance. This leadership team made themselves available to the program director to help expedite operational enhancements.
3. The following enhancements were introduced by the Program Director to counselors with implementation of all automation by July 23, 2026:
- Electronic Medical Record (EMR) workflow enhancements;
- Automated tracking and reporting tools;
- Enhanced auditing and monitoring processes; and
- Staff re-education and leadership oversight.
The Program Director established a monitoring program and an automated compliance-tracking tool within the EMR system to verify ongoing adherence to DDAP requirements. The automated EMR-based tracking tool, which shows the current program client census and the active client list for each counselor's caseload, will be reviewed weekly to verify compliance results and promptly identify and address deficiencies. The program director verified that policies for impacted processes were updated as needed to include the development and implementation of staff education completion by July 23, 2026.
4. Corrective Action and Sustainability
Any identified noncompliance with regulatory requirements, policies, or approved plans of correction will be addressed promptly through corrective action, staff education, enhanced monitoring, and additional audits as appropriate. Counselors will use the automated EMR-based tracking tool, which displays their current active client list for each counselor's caseload, and the Director or designee will monitor the tool daily to support management of active caseload requirements and reduce the risk of human error.
5. Sustained Compliance Monitoring
For sustained compliance with the plans of correction, the leadership team will use the automated EMR-based tracking tool showing the current program client census and the current active client list for each individual counselor's caseload. The Program Director or designee will conduct weekly audit reviews and monitoring of 100% of new admission client charts for a minimum of three consecutive months following implementation of corrective actions. Audit results, compliance trends, and any identified deficiencies will be reviewed by program leadership and reported through the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement. Additional corrective actions will be implemented as necessary, based on monitoring results, to verify the ongoing effectiveness of corrective measures and prevent the recurrence of deficiencies.
Implementation Timeline with Program Director overseeing each milestone:
- June 30 ? July 12, 2026: Review findings, identify barriers, and develop corrective actions collaborating with leadership, Information Services, and staff.
- July 13 ? July 20, 2026: Approval of EMR enhancements with modification of policies/standard work, education.
- July 23, 2026: EMR automated client census tracking tool for BH Additional Consent to Release Information and Active Treatment Plan due date go live. All staff were trained on tool use, expectations, and procedures for self-monitoring of active client caseload.
- July 23, 2026: Counselors were trained on where and how to access and complete BH additional consent in the EMR system.
- July 24, 2026: EMR final build completion and project "go-live" date for automated outreach to individual client follow-up with documentation in the EMR.
- July 24 ? August 15, 2026: Go-live, testing, monitoring, and process refinement for final EMR enhancement.
Responsible Party:
Program Director or Designee
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711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) 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 ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in five of the seven client records reviewed.
Client #1 was admitted on November 5, 2025 and was still active at the time of the inspection. A treatment plan update was completed on February 10, 2026 and the next update was due no later than April 11, 2026, however the update was completed on May 4, 2026.
Client #2 was admitted on December 19, 2025 and was still active at the time of inspection. A treatment plan update was completed on January 22, 2026 and the next update was due no later than March 22, 2026, however the update was completed on April 24, 2026.
Client #4 was admitted on December 23, 2025 and was discharged on May 29, 2026. A treatment plan update was completed on February 3, 2026 and the next update was due no later than April 4, 2026, however the update was completed on May 19, 2026.
Client #5 was admitted on December 3, 2025 and was discharged on April 23, 2026. The individual treatment was completed on December 30, 2025 and the first update was due no later than February 28, 2026; however, there was no update completed prior to discharge.
Client #7 was admitted on July 18, 2025 and discharged on March 9, 2026. A treatment plan update was completed on December 16, 2025 and the next update was due no later than February 14, 2026; however, there was no update completed prior to discharge.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
PA Code Title 28, Chapter 711.92(d) ? Treatment Plan Updates
1. Review of Findings
On June 29 and June 30, 2026, the Regulatory Director reviewed the survey findings with an interdisciplinary team, including representatives from Senior Operations, Privacy, Regulatory, and program leadership. The Program Director reviewed the findings with counselors and leadership to identify contributing factors and develop corrective actions.
2. Process Improvements
Effective July 23, 2026, the Program Director implemented an automated EMR-based client census tracking tool and process within the electronic medical record (EMR) to identify active clients approaching the 60-day treatment plan review requirement.
- Treatment plan review due dates were added to the automated EMR-based tracking tool, which displays the current active client census for all active clients in programs and for each counselor's caseload.
- Counselors use and review this tool daily to manage their assigned caseloads.
- The Program Director or designee also monitors and updates it.
- The Program Director or designee is the only person authorized to update the overall and individual client lists, minimizing opportunities for error across multiple accessibility levels.
This process enables real-time, immediate identification of treatment plans requiring review and will remain in place until an automated alert system is validated and implemented.
3. Automated Tracking
The Program Director collaborated with Information Services to develop an automated alert process within the EMR to notify counselors when treatment plan reviews are approaching the 60-day requirement. Implementation occurred on July 23, 2026.
4. Policy Revision
The PPMC Total Recovery Outpatient Substance Use Treatment Program Policy and Procedure 22.05 was reviewed and revised for consistency with PA Code Title 28, Chapter 711.92(d).
The revised policy includes:
- Routine monitoring of treatment plan due dates for active clients.
- Defined processes for management of missed treatment plan review appointments.
- Requirements to maintain an active treatment plan when clients fail to attend scheduled appointments, including documentation of client absence, continuation of previously agreed upon client treatment goals for follow-up treatment plan, note of client's absence on client's signature portion of treatment plan, and follow-up at the next counseling session.
- Expectations for completion and documentation of treatment plan reviews within required timeframes.
5. Record Review and Corrective Action
The records identified by the surveyor were reviewed with the responsible counselors. Although overdue treatment plan updates cannot be retrospectively corrected, the cited cases were utilized as educational examples to reinforce regulatory expectations and revised workflow requirements.
In addition, the Program Director reviewed all active client records on July 23, 2026, to identify treatment plans approaching or exceeding the 60-day review requirement for appropriate follow-up with responsible counselors.
6. Staff Education
On July 16, 2026, the Program Director re-educated counselors regarding:
- PA Code Title 28, Chapter 711.92(d);
- Revised Policy and Procedure 22.05;
- Surveyor recommendations and compliance expectations;
On July 23, 2026, the Program Director educated counselors regarding:
- New automated tracking and monitoring processes utilizing the implemented EMR-based client census tracking tool and
- Counselor responsibilities for daily review and utilization of active caseload list.
Education emphasized the requirement to review, update, and document treatment plans at least every 60 days.
7. Monitoring
For monitoring and sustained compliance, through utilizing the automated EMR-based tracking tool showing the current program client census and the current active client list for each individual counselor's caseload, the Program Director or designee will conduct bi-weekly audits of at least 100% of active client records for a minimum of three months to verify treatment plan reviews are completed and documented within required timeframes.
Any identified deficiencies will be addressed immediately through staff feedback, corrective action, and additional education as necessary.
If sustained 100% compliance is not achieved during the monitoring period, leadership will evaluate the effectiveness of the corrective actions and implement additional interventions as needed.
8. Quality Oversight
Audit results, compliance trends, and corrective actions will be aggregated monthly and reported at least quarterly to the PPMC Clinical Effectiveness and Quality Improvement (CEQI) Committee. The Committee will review findings and recommend additional actions as necessary for sustained compliance.
Responsible Party:
Program Director or Designee
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711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in one of three applicable client records reviewed.
Client #5 was admitted on December 3, 2025 and was discharged on April 23, 2026. There was no follow-up information documented in the record at the time of the inspection.
This is a repeat citation from the June 27, 2024 and August 18, 2025 annual licensing renewal inspections.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
PA Code Title 28, Chapter 711.93(a)(7) ? Follow-Up Information
1. Review of Findings
The Program Director reviewed the survey findings on June 29 and June 30, 2026, with an interdisciplinary team, including representatives from Senior Operations, Privacy, and Regulatory, regarding PA Code Title 28, Chapter 711.93(a)(7), Follow-Up Information.
2. Interim Tracking Process
Effective July 23, 2026, the Program Director implemented an automated discharge follow-up tracker in the Electronic Medical Record (EMR) for all discharged clients within the past 30 days. The log is reviewed weekly by the Program Director or designee, with assigned counselors, to verify that follow-up outreach is completed and documented within 30 days of discharge, and to identify any outstanding follow-up requirements that require intervention. This interim process will remain in place until the automated solution is implemented, validated, and demonstrates sustained compliance.
3. Automated Outreach Process
The Program Director collaborated with the Information Services Department to implement an automated post-discharge outreach process, scheduled for implementation and validation beginning July 24, 2026. The system will automatically reach out to clients post-discharge and document outreach attempts, dates, times, patient responses, and unsuccessful contact attempts within the EMR. Clients requesting additional support will be routed to the associated work queue, which will be monitored by the Program Director or designee daily. Program Director or designee will route client outreach to the appropriate counselor for follow-up. The automated process is designed to support timely follow-up outreach, engagement of clients needing continued services, and documentation in accordance with program requirements.
4. Policy Review and Revision
The PPMC Total Recovery Outpatient Substance Use Treatment Program Policy and Procedure 35.02, Post-Discharge Follow-Up, was reviewed and revised for consistency with PA Code Title 28, Chapter 711.93(a)(7). The revised policy incorporates the automated outreach process, staff responsibilities, documentation requirements, and leadership monitoring expectations to support sustained compliance.
5. System Validation and Sustainability
Automated discharge follow-up tracker in the Electronic Medical Record (EMR) displaying outreach after discharge by assigned counselors for all discharged clients within 30 days will continue through August 15, 2026. The process will remain in place until the automated system for outreach and documentation demonstrates three consecutive months of sustained compliance. Oversight and monitoring of adherence to the automated system with PA Code Title 28, Chapter 711.93(a)(7) and PPMC Total Recovery Outpatient Substance Use Treatment Program Policy and Procedure 35.02 will then continue to occur utilizing the program campaign report. This will be monitored weekly by the Program Director or designee.
6. Record Review and Corrective Action
The record identified by the surveyor was reviewed with the responsible counselor. While the missed follow-up timeframe in the cited case cannot be corrected retrospectively, the case was used as an educational opportunity to reinforce the requirement that follow-up contact and documentation occur within 30 days of discharge. In addition, discharged client records from the previous 30 days were reviewed by July 10, 2026, to verify compliance with follow-up requirements and identify any additional opportunities for corrective action.
7. Staff Education
The Program Director re-educated counselors on the requirements of PA Code Title 28, Chapter 711.93(a)(7), the revised policy, the interim tracking process, and the automated outreach process. Education emphasized timely completion and documentation of follow-up activities within 30 days of discharge, as well as staff responsibilities for monitoring and acting on follow-up requests. Training was completed on July 23, 2026.
8. Monitoring Plan
The Program Director or designee will conduct monthly audits of 100% of discharged client records requiring follow-up to verify completion and documentation of follow-up within 30 days of discharge. Monitoring will continue until three consecutive months of 100% compliance are achieved. Any identified deficiencies will be addressed immediately through corrective action, staff education, and additional monitoring as necessary. If sustained compliance is not achieved, behavioral health leadership will reassess the effectiveness of the corrective actions and implement additional interventions as needed.
Automated discharge follow-up tracker in the Electronic Medical Record (EMR) displaying outreach after discharge by assigned counselors for all discharged clients within 30 days will continue through August 15, 2026. The process will remain in place until the automated system for outreach and documentation demonstrates three consecutive months of sustained compliance. Oversight and monitoring of adherence to the automated system with PA Code Title 28, Chapter 711.93(a)(7) and PPMC Total Recovery Outpatient Substance Use Treatment Program Policy and Procedure 35.02 will then continue to occur utilizing the program campaign report. This will be monitored weekly by the Program Director or designee.
9. Quality Oversight
Results from the automated discharge follow-up tracker in the Electronic Medical Record (EMR) displaying outreach after discharge by assigned counselors will be compiled monthly and reported quarterly to the Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of ongoing quality assurance and performance improvement activities. The Committee will evaluate results and implement additional interventions as needed to verify sustained compliance. Audit results will also be reviewed by program leadership for continued adherence to approved plans of correction and to prevent recurrence of deficiencies.
Responsible Party:
Program Director or Designee
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711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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 an informed and voluntary consent to release information form from the client for the disclosure of information in one of seven client records reviewed.
Client #2 was admitted on December 19, 2025 and was still active at the time of the inspection. There was evidence of disclosures to the funding source since the start of the treatment episode; however, there was no valid consent to release information form signed by the client documented in the record prior to any of the disclosures.
This is a repeat citation from the June 27, 2024 and August 18, 2025 annual licensing renewal inspections.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
711.93(c)(2) LICENSURE
Consent to Release-Informed & Voluntary:
711.93. Client records. (c) Confidentiality.
1. Review of Findings
The Program Director reviewed the survey findings on June 29 and June 30, 2026, with an interdisciplinary team, including representatives from Senior Operations, Privacy, Regulatory, Information Services, and program leadership, regarding PA Code Title 28, Chapter 711.93(c)(2), Consent to Release Information.
Client #2 was active in the program at the time of review. BH Additional Consent to Release Information was complated with patient at next scheduled appointment on July 15, 2026.
2. Process Improvement and Verification
Effective July 21, 2026, the Program Director implemented a process requiring verification of a completed Behavioral Health Additional Consent for Substance Use Treatment Client form at the time of admission and prior to the initiation of counseling services or disclosure of information. Registration staff are responsible for verifying completion of the consent form, and counseling services may not begin until the required consent has been obtained and documented in the Electronic Medical Record (EMR).
3. EMR Workflow Enhancement
- The Program Director collaborated with the Information Services Department to implement EMR workflow enhancements requiring verification of a valid consent form before counseling services begin and prior to the disclosure of client information.
- Effective July 23, 2026, the Program Director implemented an automated EMR-based client census tracking tool and process within the electronic medical record (EMR) to identify if clients have the required BH Additional SUD Consent with resolution date to verify that this is completed annually for each active client.
- EMR tool was developed to assist counselors and leadership in identifying missing or incomplete BH Additional SUD Consent and to support ongoing monitoring of regulatory compliance.
4. Policy Review and Revision
The PPMC Total Recovery Outpatient Substance Use Treatment Program policies and procedures related to confidentiality and release of information were reviewed and revised for consistency with PA Code Title 28, Chapter 711.93(c)(2). The revised policies clarify staff responsibilities, consent-verification requirements, documentation expectations, and leadership-oversight processes to support sustained compliance.
5. Record Review and Corrective Action
The record identified by the surveyor was reviewed with the responsible counselor. While disclosures made before obtaining valid consent cannot be corrected retrospectively, the cited case was used as an educational opportunity to reinforce the requirement to obtain informed, voluntary consent and document it before disclosing client information.
The Program Director reviewed active client records on July 23, 2026, to verify that required consent forms were present, complete, and appropriately documented. Any identified deficiencies were addressed immediately with the admissions staff so they could be completed at the next appointment check-in, and with counselors to verify they were completed at the next scheduled appointment session.
For virtual-only clients, admission processes were reviewed and updated to ensure that BH Additional SUD Consent is completed by the patient prior to the intake session, along with other required paperwork, and that patients are aware of this procedure.
6. Staff Education
The Program Director re-educated counselors, registration staff, and other applicable personnel regarding:
- PA Code Title 28, Chapter 711.93(c)(2);
- Revised confidentiality and release of information policies;
- Requirements for obtaining informed and voluntary consent prior to disclosure of client information;
- Documentation expectations; and
- The revised workflow and verification process.
Education emphasized that a valid consent must be obtained and documented prior to the initiation of counseling services and before the disclosure of information contained in the client record. Staff retraining was completed on July 16, 2026.
Education regarding consent and admission required paperwork, including BH Additional consent for SUD treatment specific to virtual-only patients, was completed with admissions staff, including Patient Service Representatives, Behavioral Health Coordinator, and Counselors, on July 23, 2026.
7. Monitoring Plan
For monitoring and sustained compliance, utilizing the automated EMR-based tracking tool verifying the completion of the BH Additional SUD treatment Consent, the The Program Director or designee will conduct monthly audits of 100% of newly admitted client records and 100% of active charts representing 100% of the active patient census, to verify that required consent forms are present, complete, and obtained prior to any disclosure of information. Monitoring at this level of oversight will continue until three consecutive months of 100% compliance are achieved.
Any identified deficiencies will be addressed immediately through corrective action, staff education, and additional monitoring as necessary. If sustained compliance is not achieved, behavioral health leadership will reassess the effectiveness of the corrective actions and implement additional interventions as needed.
8. Quality Oversight
Results from medical record audits will be compiled monthly and reported quarterly to the Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of ongoing quality assurance and performance improvement activities. The Committee will evaluate results and implement additional interventions as needed to verify sustained compliance. Audit results will also be reviewed by program leadership for continued adherence to approved plans of correction and to prevent recurrence of deficiencies.
Responsible Party:
Program Director or Designee
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711.93(c)(2)(iv) LICENSURE Signature Client/Guardian
711.93. Client records.
(c) Confidentiality.
(2) 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:
(iv) The dated signature of the client or guardian.
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Observations
Based on a review of client records, the facility failed to ensure informed and voluntary consent to release information forms included the dated signature of the client in two of seven applicable records reviewed.
Client #4 was admitted on December 23, 2025 and was discharged on May 29, 2026. The release of information form to the funding source did not include documentation of the dated signature of the client.
Client #5 was admitted on December 3, 2025 and was discharged on April 23, 2026. The release of information form to the funding source did not include documentation of the dated signature of the client.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
711.93(c)(2)(iv) LICENSURE
Signature Client/Guardian: 711.93. Client records. (c) Confidentiality.
1. Review of Findings
The Program Director reviewed the survey findings on June 29 and June 30, 2026, with an interdisciplinary team, including representatives from Senior Operations, Privacy, Regulatory, Information Services, and program leadership, regarding PA Code Title 28, Chapter 711.93(c)(2), Consent to Release Information.
2. Process Improvement and Verification
Effective July 23, 2026, the Program Director implemented an automated process to verify the Behavioral Health Additional Consent for Substance Use Treatment Client form is obtained, completed, and documented in the Electronic Medical Record (EMR) at the time of admission and prior to the initiation of counseling services or disclosure of information. Active client records are reviewed routinely by the Program Director or designee to verify required consent documentation is maintained.
3. EMR Workflow Enhancement
- The Program Director collaborated with the Information Services Department to implement EMR workflow enhancements requiring verification of a valid consent form before counseling services begin and prior to the disclosure of client information.
- Effective July 23, 2026, the Program Director implemented an automated EMR-based client census tracking tool and process within the electronic medical record (EMR) to identify if clients have the required BH Additional SUD Consent with resolution date to verify that this is completed annually for each active client.
- EMR tool was developed to assist counselors and leadership in identifying missing or incomplete BH Additional SUD Consent and to support ongoing monitoring of regulatory compliance.
4. Policy Review and Revision
The PPMC Total Recovery Outpatient Substance Use Treatment Program policies and procedures related to confidentiality and release of information were reviewed and revised for consistency with PA Code Title 28, Chapter 711.93(c)(2). The revised policies clarify staff responsibilities, documentation requirements, consent verification processes, and leadership oversight expectations to support sustained compliance.
5. Record Review and Corrective Action
The record identified by the surveyor was reviewed with the responsible counselor. While disclosures occurring prior to obtaining a valid consent cannot be retrospectively corrected, the cited case was utilized as an educational opportunity to reinforce the requirement that informed and voluntary consent be obtained and documented prior to the disclosure of client information.
In addition, the Program Director conducted a review of active client records on July 23, 2026, to verify that required consent forms were present and complete and to identify any additional opportunities for corrective action.
6. Staff Education
The Program Director re-educated counselors, registration staff, and other applicable personnel regarding:
- PA Code Title 28, Chapter 711.93(c)(2);
- Revised confidentiality and release of information policies;
- Requirements for obtaining informed and voluntary consent prior to disclosure of client information;
- Documentation expectations; and
- The revised workflow and verification process.
Education emphasized that a valid consent must be obtained and documented prior to the initiation of counseling services and before the disclosure of information contained in the client record. Staff retraining was completed on July 16, 2026.
Education regarding consent and admission required paperwork, including BH Additional consent for SUD treatment specific to virtual-only patients, was completed with admissions staff, including Patient Service Representatives, Behavioral Health Coordinator, and Counselors, on July 23, 2026.
7. Monitoring Plan
For monitoring and sustained compliance, utilizing the automated EMR-based tracking tool verifying the completion of the BH Additional SUD treatment Consent, the The Program Director or designee will conduct monthly audits of 100% of newly admitted client records and 100% of active charts representing 100% of the active patient census, to verify that required consent forms are present, complete, and obtained prior to any disclosure of information.
Monitoring at this level of oversight will continue until three consecutive months of 100% compliance are achieved.
Any identified deficiencies will be addressed immediately through corrective action, staff education, and additional monitoring as necessary. If sustained compliance is not achieved, behavioral health leadership will reassess the effectiveness of the corrective actions and implement additional interventions as needed.
8. Quality Oversight
Results from medical record audits will be compiled monthly and reported quarterly to the Clinical Effectiveness and Quality Improvement (CEQI) Committee as part of ongoing quality assurance and performance improvement activities. The Committee will evaluate results and implement additional interventions as needed to verify sustained compliance. Audit results will also be reviewed by program leadership to verify continued adherence to approved plans of correction and prevent recurrence of deficiencies.
Responsible Party:
Program Director or Designee
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