INITIAL COMMENTS
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This report is a result of an on-site complaint investigation, licensure renewal inspection and methadone monitoring conducted on December 1, 2021 through December 3, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Kirkbride 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the educational and/or experiential qualifications of the position in one of eight applicable personnel records reviewed.
Employee #7 was hired on October 18, 2021 and was still in the position at the time of the inspection. The employee had a qualifying bachelor's degree; however, the employee had only 6 months of clinical experience in a health or human service agency prior to hiring.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Based on the surveyor's findings that Employee #7 did not yet have the necessary experience to qualify for the "counselor" position, their job position and duties were changed on December 23, 2021 from that of a "Counselor" to a "Behavioral Specialist". Moving forward, HR Director (or designee) will also screen all potential candidates for the position of "counselor" prior to the interview process to ensure that they meet the minimum 1 year of clinical experience (and other mandated requirements) for the position. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to develop an individual training plan with input from both the employee and the supervisor in three of twenty applicable personnel records reviewed.
Employee # 1 was hired as the project director/facility director on March 1, 2017. The individual training plan was signed by the employee and supervisor on June 24, 2021; however, there were no trainings listed on the plan.
Employee # 2 was hired as a clinical supervisor on October 6, 2004. The individual training plan was signed by the employee and supervisor on June 24, 2021; however, there were no trainings listed on the plan.
Employee # 18 was hired as a counselor on July 19, 2021. The individual training plan was signed by the employee and supervisor on June 28, 2021; however, there were no trainings listed on the plan.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review of the 3 employee files it was determined that a problem had occurred with the electronic system used to document the individual training plan during the (now current) training year running from period July 1, 2021 through June 30, 2022. The individual plans for the employees listed were updated in writing as of 12/30/21 to include relevant trainings during the remainder of the training year until such time as a review of the electronic system occurs to prevent any similar problem in the future. Moving forward, the HR Director (or designee) is responsible for ongoing monitoring for completion of training plans prior to filing in personnel records. Any variances identified will be brought to the attention of the relevant manager/director for remediation with their staff. Any findings will be discussed monthly in rehab dashboard meeting. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in three of six applicable personnel records reviewed.
Employee # 21 was hired as a behavioral health tech on November 18, 2019 and was due to have the TB/STD training no later than November 18, 2021. The TB/STD training was not completed at the time of the inspection.
Employee # 22 was hired as a behavioral health tech on November 18, 2019 and was due to have the HIV/AIDS training and the TB/STD training no later than November 18, 2021. The HIV/AIDS training and the TB/STD training were not completed at the time of the inspection.
Employee # 23 was hired as a behavioral health tech on September 23, 2019 and was due to have the HIV/AIDS training and the TB/STD training no later than September 23, 2021. The HIV/AIDS training and the TB/STD training were not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #21 is no longer employed with our facility. The HR Director (or designee) will follow through with the remaining 2 identified employees to ensure completion of the required communicable disease trainings at the earliest opportunity they are available. Moving forward, HR will monitor ongoing compliance with mandatory training sessions and due dates for all employees and review findings with department managers monthly. Any variances will be reported monthly to management team for review in rehab dashboard meeting. |
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 ensure that each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2020 through June 30, 2021 training year in one of five applicable personnel records reviewed.
Employee # 20 was hired as a counselor on December 15, 2014. The personnel record documented 24 hours of training received during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Director (or designee) will monitor ongoing monthly compliance with mandatory training hours and due dates for all employees and review findings with department managers monthly. Any such variances will be reported monthly to management team for review in rehab dashboard meeting. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection conducted on December 3, 2021 at approximately 11:20 AM, the facility failed to ensure that each bedroom had a bed with a fire-retardant mattress that was in good repair. In patient room 217, there was a mattress that had a large hole cut out of the side.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The mattress was removed and a new mattress installed for the client on December 17, 2021. All maintenance issues identified are called into the Engineering's Facility Request line or submitted via email into their electronic ticket system and are dispatched/ addressed by the Office Manager in order of priority in coordination with the Property Manager. Maintenance issues will be reviewed daily by the Office Manager (or designee) who will monitor and track any identified problems to ensure their resolution within a timely manner. Monthly EOC rounds will also be used to identify and report any similar areas of concern which will be reported to the Property Manager for resolution, and a summary of findings reported to leadership during monthly Safety Meeting. |
705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based on a physical plant inspection conducted on December 3, 2021 between approximately 10:30 AM and 11:30 AM, the facility failed to provide a storage area for a client's clothing in good repair. There were dressers with missing and/or broken drawers in patient rooms 218, 311, 315, 509, 511, and 513.
This is a repeat citation from the January 5, 2021 through January 7, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All broken dressers identified were removed and new dressers installed between December 6th and 17th, 2021. All maintenance issues identified are called into the Engineering's Facility Request line or submitted via email into their electronic ticket system and are dispatched/ addressed by the Office Manager in order of priority in coordination with the Property Manager. Maintenance issues submitted will be reviewed daily by the Office Manager who will monitor and track any identified problems to ensure their resolution within a timely manner. Monthly EOC rounds will also be used to identify and report any similar areas of concern which will be reported to the Property Manager for resolution, and a summary of findings reported to leadership during monthly Safety Meeting. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection conducted on December 3, 2021 between 11:00 AM and 11:30 AM, the facility failed to provide privacy and slip-resistant surfaces in all showers. The shower in room 110 did not have a privacy shower curtain. Additionally, the shower in room 320 did not have a slip-resistant surface.
This is a repeat citation from the January 5, 2021 through January 7, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The shower curtain in room 110 was replaced on December 22, 2021. New slip-resistant strips were installed in room # 320 on December 17, 2021. All maintenance issues identified are are called into the Engineering's Facility Request line or submitted via email into their electronic ticket system and are dispatched/ addressed by the Office Manager in order of priority in coordination with the Property Manager. Maintenance issues submitted will be reviewed daily by the Office Manager who will monitor and track any identified problems to ensure their resolution within a timely manner. Monthly EOC rounds will also be used to identify and report any similar areas of concern which will be reported to the Property Manager for resolution, and a summary of findings reported to leadership during monthly Safety Meeting. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on December 3, 2021 between 10:00 AM and 11:30 AM, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The following bathrooms were found to not be functional, clean, or sanitary at the time of the inspection:
-The bathroom in room 013 had a burnt outlet.
-The bathroom in room 206 had damaged drywall and peeling paint from a prior water leak on the ceiling and wall.
-The bathroom in room 210 had graffiti on the wall and door.
-The bathroom in room 215 had a sink with a corroded and damaged faucet.
-The bathroom in room 313 had a wall with chipped and peeling paint.
-The bathroom in room 402 had a shower with a handle that had a build-up of dirt and grime.
-The bathroom in room 404 had a sink that was not properly secured to the wall.
-The bathroom in room 407 had a rusted tub grab-bar.
-The bathroom in room 408 had a shower with a wall that had a build-up of dirt and grime.
-The female bathroom in the outpatient part of the program had damaged drywall and peeling paint due to a prior leak.
This is a repeat citation from the January 5, 2021 through January 7, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The burnt outlet in Room 013 was replaced on December 20, 2021. The drywall and peeling paint in room 206 was repaired on December 23, 2021. The cleaning of graffiti in room 210 was completed by December 23, 2021. The faucet in room 215 was replaced on December 16, 2021. The wall in room # 313 was repaired on December 23, 2021. have been fixed. The bathrooms in rooms 402 and 408 were cleaned by housekeeping to address identified issues - cleaning continues to be an ongoing process. Room 404 was closed pending completion of repairs to sink which are still ongoing. The grab-bar for the bathroom of room 407 was examined and what appeared to be rust was simply grime which was removed on December 18, 2021. The drywall and peeling paint was addressed in the female bathroom in the OP area on December 23, 2021. All maintenance issues identified are called into the Engineering's Facility Request line or submitted via email into their electronic ticket system and are dispatched/ addressed by the Office Manager in order of priority in coordination with the Property Manager. Maintenance issues called in will be reviewed daily by the Office Manager who will monitor and track any identified problems to ensure their resolution within a timely manner. Monthly EOC rounds will also be used to identify and report any similar areas of concern which will be reported to the Property Manager for resolution, and a summary of findings reported to leadership during monthly Safety Meeting. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency or organization to whom the disclosure is made to on consent to release information forms in two of twenty-one client records reviewed.
Client # 2 was admitted to the inpatient non-hospital detoxification activity on November 27, 2021 and was still active at the time of the inspection. A release of information form was signed and dated by the client and witness on November 27, 2021; however, the form failed to document the name of the person, agency or organization to whom the disclosure would be made.
Client # 3 was admitted to the inpatient non-hospital detoxification activity on November 28, 2021 and was still active at the time of the inspection. Release of information forms for a primary care physician and an emergency contact were signed and dated by the client and witness on November 28, 2021; however, both forms failed to document the name of the person, agency or organization to whom the disclosures would be made.
This is a repeat citation from the January 5, 2021 through January 7, 2021 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Both clients (#2 and #3) subsequently discharged and files were closed so were unable to be followed up with at the time. However, #2 just readmitted on 12/28 and an audit of her current record was done to ensure compliance with the regulation and all active release of information forms are complete. Admission Manager has conducted a re-training of 11 Admission staff by 12/23 - (3 weekend staff remain - to be completed by Jan. 3rd, 2022) regarding appropriate consent form documentation with all fields to be fully and accurately completed. Admission Manager will conduct random weekly audits of admission records for a period of 3 months to ensure that consent form documentation and any release of information is being adhered to, per regulations, and will conduct remediation with staff upon any findings. Compliance Analyst will also conduct random monthly validation audits. Any variances identified will be brought to the attention of the Admissions Manager immediately for remediation, and findings discussed monthly in rehab dashboard meeting. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment in one of eighteen applicable patient records reviewed.
Patient # 13 was admitted to the inpatient non-hospital activity on September 3, 2021 and was still active at the time of the inspection. There was no documentation of a face-to face determination documented in the patient record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Compliance Director will coordinate monthly random chart audits for a period of 3 months to verify completion of the Physician's Documentation of Opiate Addiction. Any variances identified will be brought to the attention of the Medical Director immediately for remediation with staff who are responsible for its completion, and findings discussed monthly in rehab dashboard meeting. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the narcotic treatment program failed to complete a random urinalysis at least monthly in six of eighteen applicable patient records reviewed.
Patient # 12 was admitted to the inpatient non-hospital activity on August 25, 2021 and was still active at the time of inspection. There was no documented drug screen urinalysis, in the record, for the month of November 2021.
Patient # 13 was admitted to the inpatient non-hospital activity on September 3, 2021 and was still active at the time of the inspection. There was no documented drug screen urinalysis, in the record, for the month of November 2021.
Patient # 14 was admitted to the inpatient non-hospital activity on August 31, 2021 and was still active at the time of the inspection. There was no documented drug screen urinalysis, in the record, for the month of November 2021.
Patient # 15 was admitted to the outpatient maintenance activity on June 12, 2021 and was still active at the time of the inspection. There was no documented drug screen urinalysis, in the record, for the months of August 2021 and November 2021.
Patient # 17 was admitted to the outpatient maintenance activity on November 11, 2021 and was still active at the time of the inspection. There was no documented drug screen urinalysis, in the record, for the month of November 2021.
Patient # 21 was admitted to the outpatient maintenance activity on August 10, 2021 and was still discharged on October 12, 2021. There was no documented drug screen urinalysis, in the record, for the month of September 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Shift Director is responsible for monitoring and ensuring ongoing UDS completion for those clients requiring 30-day UDS's as per stated regulation. The Shift Director will cross-reference those individuals' completed UDS's with the census sheet to ensure that all names listed for UDS collection have been collected, results received and filed, and follow-up with unit staff as needed. Any variances identified will be reported to the Director of Nursing (or designee) and followed up within 24 hours to ensure that a UDS is obtained. Any outstanding variances will be reported monthly during rehab dashboard meeting |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document long term goals for treatment on the individual treatment and rehabilitation plan in seven of seven applicable client records reviewed.
The individual treatment and rehabilitation plan for each outpatient activity client record reviewed did not document long-term goals for treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director responsible for oversight of the Outpatient Program in which these issues were identified has updated the treatment plan documentation to include both short and long-term goals for treatment as formulated by both staff and client and has reviewed these changes with staff responsible for the relevant documentation. Compliance Analyst will conduct random monthly validation audits to confirm that this information is being documented. Any variances identified will be brought to the attention of the Program Director immediately for remediation, and findings discussed monthly in rehab dashboard meeting. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include an aftercare plan, in three of three applicable client records reviewed.
Client #19 was admitted into the outpatient level of care on October 21, 2021 and was successfully discharged on November 22, 2021. There was no documentation of an aftercare plan in the record at the time of the inspection.
Client #20 was admitted into the outpatient level of care on July 6, 2021 and was successfully discharged on August 6, 2021. There was no documentation of an aftercare plan in the record at the time of the inspection.
Client #21 was admitted into the outpatient level of care on August 13, 2021 and was successfully discharged on October 12, 2021. There was no documentation of an aftercare plan in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The 3 clients referenced in the Outpatient program had been absent and unable to be reached for a period of time and thus coordinated aftercare planning had not been possible. Also, their cases had not yet been closed out as outreach attempts were still being made in the hopes that reintegration into treatment might still occur. Moving forward, the Program Director has updated the process so that clients' cases must be closed out no later than 30 days following the last treatment episode of the client and the aftercare plan, if applicable, completed, and has reviewed these changes with staff responsible for the relevant documentation. Medical Records Manager (or designee) will conduct monthly validation audits of closed Outpatient records to confirm that this information is being documented and in the timeframe indicated. Any variances identified will be brought to the attention of the Program Director immediately for remediation, and findings discussed monthly in rehab dashboard meeting. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include a discharge summary, in three of three applicable client records reviewed.
Client #19 was admitted into the outpatient level of care on October 21, 2021 and was successfully discharged on November 22, 2021. There was no documentation of a discharge summary in the record at the time of the inspection.
Client #20 was admitted into the outpatient level of care on July 6, 2021 and was successfully discharged on August 6, 2021. There was no documentation of a discharge summary in the record at the time of the inspection.
Client #21 was admitted into the outpatient level of care on August 13, 2021 and was successfully discharged on October 12, 2021. There was no documentation of a discharge summary in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The 3 clients referenced in the Outpatient program had been absent and unable to be reached for a period of time and their cases had not yet been closed out as outreach attempts were still being made in the hopes that reintegration into treatment might still occur. Moving forward, the Program Director has updated the process so that clients' cases must be closed out no later than 30 days following the last treatment episode of the client and the discharge summary completed and has reviewed these changes with staff responsible for the relevant documentation. Medical Records Manager (or designee) will conduct monthly validation audits of closed Outpatient records to confirm that this information is being documented and in the timeframe indicated. Any variances identified will be brought to the attention of the Program Director immediately for remediation, and findings discussed monthly in rehab dashboard meeting. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in three of three applicable client records reviewed.
Client #19 was admitted into the outpatient level of care on October 21, 2021 and was successfully discharged on November 22, 2021. There was no follow-up information documented in the record as of the date of the inspection.
Client #20 was admitted into the outpatient level of care on July 6, 2021 and was successfully discharged on August 6, 2021. There was no follow-up information documented in the record as of the date of the inspection.
Client #21 was admitted into the outpatient level of care on August 13, 2021 and was successfully discharged on October 12, 2021. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The 3 clients referenced in the Outpatient program had been absent and unable to be reached for a period of time and their cases had not yet been closed out as outreach attempts were still being made in the hopes that reintegration into treatment might still occur. Moving forward, the Program Director has updated the process so that clients' cases must be closed no later than 30 days following the last treatment episode of the client and has trained appropriate staff on the changes. Final follow-up documentation will then occur within 7 days of the date the client's case has been officially closed. Medical Records Manager (or designee) will conduct monthly validation audits of closed Outpatient records to confirm that this information is being documented and in the timeframe indicated. Any variances identified will be brought to the attention of the Program Director immediately for remediation, and findings discussed monthly in rehab dashboard meeting. |