INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on May 21, 2024 through May 22, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Consortium 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 reviewed met the qualifications of the position in one of four applicable personnel records reviewed.
Employee # 16 was hired as a counselor on April 1, 2024 and was still in the position at the time of the inspection. The employee had a master's degree; however, the degree was not obtained from an accredited college.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #16 has a verified BS in MH Nursing:
- The TSS/HR Manager received the CES Professional Report from CGFNS, International Credential & Evaluation Organization for the Nursing and Allied Health Professions and entered the documents into the employee's staff file
- The report confirms that as of January 2019, the employee's BS in Mental Health Nursing is comparable to the completion of a BS in Nursing in the United States. The report also confirms registration as a Registered Nurse, comparable to the registration of a first-level Registered Nurse in the United States
*Action Steps:
- The TSS/HR Manager will verify all candidate educational degrees and licenses prior to offering a New Hire Letter
- The TSS/HR Manager will utilize an International Credentialing and Evaluation organization to verify all degrees awarded outside of the US prior to offering a New Hire Letter to the candidates
*Monitoring Process:
- The Division Director will confirm completion of the Action Steps with the TSS/HR Manager before accepting a start date for the candidates
- The TSS/HR Director will monitor and provide direction to ensure that the TSS/HR Manager follows the requirements
Effective 06/17/2024
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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 two of three applicable personnel records reviewed.
Employee # 14 was hired as a counselor on March 27, 2023 and was due to have the HIV/AIDS and TB/STD trainings no later than March 27, 2024. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 17 was hired as a counselor on March 20, 2023 and was due to have the TB/STD training no later than March 20, 2024. The TB/STD training was 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 # 14 will be scheduled in July for HIV/AIDS and TB/STD. The trainings will be completed by August 30, 2024.The Program Manager will assist the employee with scheduling the virtual trainings, ensure that the trainings were completed by collecting the certifications, acknowledgement form, and evaluation. The Program Manager will submit the packet to TSS/HR to be entered into the employee's staff file. The Division Director will cover the fee for the trainings.
Employee # 17 completed HIV/AIDS 6hr on 12/2/2022 and TB/STD 4 hrs on 11/3/2016. The proof of training was not entered into the employee's staff files. Effective 06/18/2024 the proof of trainings will be entered into the employee's staff file by the TSS/HR Manager.
Effective 6/18/2024: To prevent missing documentation in staff files,the program and the TSS/HR departments will comply with the following plan;
- All Therapists will be scheduled for and complete the required trainings.
-A tracker will be utilized to list all staff, their required trainings, the dates employees are scheduled for the trainings, and the date of completion for the trainings
* Responsible Party:
Therapists - Compliance
Clinical Supervisors - Scheduling
Program Manager - Tracking / Submission
Division Director - Will monitor all activity
- Division Director will create a shared "Staff Documents & Training Certificates" folder in Teams for Clinical Supervisors and TSS/HR Manager.
- Supervisors will submit documents to TSS/HR via the shared folder, and notify TSS/HR every Friday via email of the documents waiting to be filed.
- The Program Manager will be copied on all submission notifications, view the submitted files, and enter the information of the tracker
- TSS will retrieve the submitted documents and enter them into the staff files
* Monitoring;
- Division Director will create the Teams folders and ensure that program management staff and TSS have access to the shared folder
- TSS staff and Program Manager will communicate via email by the last day of each month to confirm that the submitted certificates were entered in the staff files
* Responsible Party
- Division Director
- Program Manager
- TSS/HR Manager
Effective 6/18/2024.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of annual training during the facility's January 2023 through December 2023 training year in one of one applicable personnel record reviewed.
Employee #1 was hired as the Project Director on December 3, 2001. The personnel record documented 9 hours of annual training during the training year reviewed.
This is a repeat citation from the June 15, 2022 and June 13, 2023 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 will complete 12 hours of training annually.
The staff person, Special Assistant to the CEO will register Employee #1 for 12 hours of training, utilizing choices of the topics listed in the standards.The Special Assistant to the CEO will provide TSS/HR with proof of trainings for staff file of Employee #1.
The Special Assistant and the Division Director will be responsible to monitor this activity.
Effective 7/1/2024 |
705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection, the facility failed to maintain all structures, fences, and playground equipment on the grounds of the facility so as to be free from any danger to health and safety.
At approximately 10:30 AM on May 22, 2024, the fire escape steps at the front of the building were found to be rusting and deteriorating.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On June 18, 2024 the CFO contacted an attorney for the company who reached out to a contact person in the city department. The City of Philadelphia has ownership of the facility located at 451 University Ave, Phila. PA 19104 and the Consortium, Inc. UCRC Program are tenants of the facility. The attorney informed the city department of the urgent need for repairs to the Fire Exit Stairs. The contact person responded that they would respond with a plan of action shortly.
The CFO is responsible to monitor this activity.
The Facilities Manager will reach out to at least three companies by July 8, 2024 to arrange for estimates of the needed repairs and submit the estimates to the CFO for review.
The CFO will collaborate with the City of Philadelphia to determine the best course of action to have the repairs completed by September 3, 2024.
Corporate QUALITY ASSURANCE DEPARTMENT:
The QA Director or designated QA staff will facilitate bi-monthly physical plant rounds to ensure the deficiency does not reoccur and to document any other observations regarding the the buildings structure both inside and outside. The QA staff observations will be presented and discussed in a QA / Management bi-monthly meeting. A plan will be put in place to immediately address any new or reocurring physical plant issues. All meetings will be documented.The first site observation rounds and follow up meeting will be scheduled for September 2024.
Responsible Staff: Corporate QA Manager and Division Director
Effective: 9/03/2024
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate each toilet and washroom by an exhaust fan or a window.
On May 22, 2024, at approximately 10:30 AM, the bathroom exhaust fan in the men's second floor bathroom was not operable and there was no window in the bathroom.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Facilities Staff will replace the old exhaust fan in the 2nd floor men's room.
The Facilities Manager will be responsible for purchasing the new exhaust fan. The Facilities Manager will be responsible for ensuring the replacement of the fan is completed timely and working properly.
The Division Director will be responsible to check that the work was completed timely and working properly.
Effective 7/1/2024 |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year July 1, 2021 through June 30, 2022.
This is a repeat citation from the June 15, 2022 and June 15, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new independent auditor was engaged and has submitted the 2021 financial audit to the city. The independent auditor projects the submission of year 2022 in September 2024, and year 2023 by November 2024.
The Fiscal Director is responsible to ensure the independent auditor has all of the required information for timely completion of the 2024 financial audit.
The CEO is responsible to monitor the progress of this process.
Effective 7/1/2024 |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of nine client records reviewed.
Client # 8 was admitted on December 15, 2023 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The consent for the funding source was located, after the DDAP exit, in the chart of Clent #8 within the Custom Clinical Forms folder. The staff completing the document with Client #8 neglected to use the "save to Document Manager" option, which prevented the auditors from viewing the form as the EMR- Audit Manager Account does not provide for that permission. The funding consent is now saved in the Document Manager for Client #8.
The staff completing the Custom Clinical Forms with clients are responsible to use the "save to Document Manager" option once the forms are dated and signed by both parties.
The Intake Supervisor is responsible to check for the completion of that step when auditing the intake charts.
The Clinical Supervisor is responsible to check for completion of that step when auditing active charts for annual updates.
The Program Manager will be responsible for monitoring the process.
The facility is transitioning to a new EMR system during the summer of 2024 which will allow permissions for total access via the Audit Manager accounts.
Effective 8/1/2024 |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of nine client records reviewed.
Client # 6 was admitted on May 7, 2024 and was still active at the time of the inspection. The release of information form to the primary care physician was signed by the client on May 7, 2024; however, the release form did not include the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Primary Care Physician Consent for Clent #6 will be updated with the client, documenting all of the specific information to be released.
The Primary Therapist is responsible to complete this assignment.
The Clinical Supervisor is responsible to ensure that the assignment is completed and all required elements are documented.
The Program Manager is responsible to facilitate a documentation training for all staff who access the client charts.
The Intake Supervisor is responsible to audit all admissions chart documentation for completion.
The Clinical Supervisors are responsible to review consents for completion during their monthly chart audits.
The Program Manager is responsible to ensure theses steps are completed.
Effective 7/1/2024 |
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.
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Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month, including one hour of individual psychotherapy, during the patient's first 2 years, in one of six patient records reviewed.
Patient #1 was admitted on September 1, 2023 and was discharged on May 1, 2024.
The patient record documented 30 minutes of psychotherapy during the month of February 2024 and 35 minutes of psychotherapy during the month of March 2024.
This is a repeat citation from the June 15, 2022 and June 15, 2023 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be required to utilize the updated Service Count Tracker to ensure that all clients receive their required psychotherapy hours.
This tracker will be reviewed every Monday by the Clinical Supervisors who will review and document any missed service opportunities with the therapists.
The Clinical Supervisors will ensure that any missed service opportunities are scheduled and the clients placed on hold for the sessions.
The Program Manager is responsible to monitor this process along with the weekly Productivity Report and review any discrepancies with the therapist and supervisors.
The Division Director is responsible to monitor the progress of these activities.
Effective 7/1/2024 |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of the facility's unusual incident reports, the facility failed to notify the Department within 48 hours of an incident involving death or serious injury due to trauma, suicide, medication error or unusual circumstances.
The facility was notified of an off-site death of an active client on October 17, 2023; however, the incident was reported to the Department on October 24, 2023. Additionally, the facility was notified of an off-site death of an active client on May 7, 2024; however, the incident was reported to the Department on May 14, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Division Director will facilitate an in person Incident Report Training for all staff in August 2024.
All program staff will be responsible to verbally report incidents to any supervisor on site at their earliest knowledge of the incident.The supervisor receiving the information will direct staff to complete and submit an Internal Incident Report Form within 24hrs.
The supervisor receiving the information will determine the level of reporting by referring to the program's Incident Reporting Policy. If the incident qualifies as a DDAP Reporting Event,the supervisor will immediately notify the following managers via email:
Administrative Supervisor, Program Manager, and Division Director.
The supervisor will complete and submit the DDAP Unusual Incident Report within 24hrs on the DDAP Event platform, save the document as a pdf, and attach the document to an email addressed to the following staff:
Administrative Supervisor, Program Manager, Division Director, Corporate Quality Director.
The Division Director will be responsible to monitor compliance.
Effective:7/1/2024 |
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:
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Observations
Based on a review of client records, the facility failed to ensure individual treatment and rehabilitation plans were completed and developed with the client in two of five applicable client records reviewed.
Client #1 was admitted on September 1, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was due to be completed no later than October 1, 2023; however, the individual treatment and rehabilitation plan was completed on October 19, 2023.
Client #7 was admitted on March 11, 2024 and was still active at the time of the inspection. There was no individual treatment and rehabilitation plan documented 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
Client #1 is discharged as of 5/1/2024.
Client #7 is discharged as of 6/12/2024, therefore we cannot make their charts whole.
Effective 8/1/2024, all clinical staff and clinical supervisors will be retrained on documentation requirements and the expectation of utilizing the Document Tracker to review what is due for each member prior to the start of their individual sessions.
The Program Manager will facilitate the training for all current and new staff.
The Division Director will monitor the requirements.
Effective 7/1/2024 |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every sixty days in five of seven applicable client records reviewed.
Client #3 was admitted on May 2, 2018 and was discharged on August 7, 2023. A treatment plan update was completed on May 19, 2023, and the next update was due no later than July 19, 2023; however, the update was completed on July 24, 2023.
Client #4 was admitted on August 23, 2023 and was still active at the time of inspection. A treatment plan update was completed on January 4, 2024, and the next update was due no later than March 1, 2024; however, the update was completed on April 30, 2024.
Client #5 was admitted on March 21, 2006 and was still active at the time of inspection. A treatment plan update was completed on October 4, 2023, and the next update was due no later than December 4, 2023; however, the update was completed on December 18, 2023.
Client #8 was admitted on December 5, 2023 and was still active at the time of inspection. The individual treatment and rehabilitation plan was completed on December 5, 2023, and an update was due no later than February 5, 2024; however, the update was completed on March 19, 2024.
Client #9 was admitted on November 10, 2023 and was still active at the time of inspection. A treatment plan update was completed on March 12, 2024, and the next update was due no later than May 12, 2024; however, the update was completed on May 20, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #3, #4, #5, #6, #8, and #9 were all on caseloads with staff vacancies. All services for these caseloads were being provided by the Clinical Supervisors. The objective was to provide all required and needed services for these clients as well as meet timely with them for Treatment Planning sessions, however not all clients could be scheduled before or on their Tx Plan due dates and the services could not be completed until a later date during the same month.
All (6) staff vacancies are filled as of 6/14/2024 and the last (2) new hires are expected to begin work on 6/28/2024.
The Clinical Supervisors will utilize the Documentation Tracker to schedule and facilitate the remaining June Tx Planning sessions and the upcoming July Treatment Planning sessions as they train and acclimate the new hires to the document expectations.
The Program Manager is responsible to monitor and supervise this activity.
The Program Manager is responsible to provide Documentation Training for all clinical staff in July and August 2024.
The Division Director is responsible to monitor this activity.
Effective 7/1/2024 |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license 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 administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year was submitted and approved by the Department for the June 15, 2022 and June 15, 2023 annual licensing inspections. Failing to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services for the project's preceding fiscal year was again found to be a deficiency in the May 22, 2024 licensing inspection.
A plan of correction for failing to ensure that the project director completed at least 12 clock hours of annual training was submitted and approved by the Department for the June 15, 2022 and June 15, 2023 annual licensing inspections. Failing to ensure that the project director completed at least 12 clock hours of annual training was again found to be a deficiency in the May 22, 2024 licensing inspection.
A plan of correction for failing to provide each patient an average of 2.5 hours of psychotherapy per month, including one hour of individual psychotherapy, during the patient's first 2 years was submitted and approved by the Department for the June 15, 2022 and June 15, 2023 annual licensing inspections. Failing to provide each patient an average of 2.5 hours of psychotherapy per month, including one hour of individual psychotherapy, during the patient's first 2 years was again found to be a deficiency in the May 22, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding the annual audit: The company has engaged with a new independent public accounting firm who has completed the Fiscal Year 2021 audit and submitted the information to the City of Philadelphia. The independent accounting firm reports that Fiscal Year 2022 is currently in progress and Fiscal Year 2023 will be processed when 2022 is completed.
The CFO is responsible to monitor.
Effective: 6/24/2024
Regarding the Project Director's Trainings: The Special Assistant to the CEO/President has agreed to work with Employee #1 to develop a training plan and register the Project Director for 12hrs of trainings from the list of areas documented in 704.11(d)(2. The Special Assistant will confirm completion of each training, collect and submit the training documents to TSS/HR for the employee's file, and inform the Division Director of the status.
The Division Director is responsible to monitor.
Effective July 1, 2024
Regarding Psychotherapy Hours:
The Division Director is responsible to update the Services Trackers to identify the members who are enrolled, 2 years or less and require the 2.5 hrs of psychotherapy each month including one hour of individual psychotherapy.
This will be accomplished by clearly identifying the admissions dates of the members on each caseload and providing a column to document the dates of the groups and of the individual sessions.The Counselors will receive training and be responsible for documenting the dates on the their trackers.
The Clinical Supervisors will be responsible for reviewing the trackers weekly and verifying the services in the Client's charts to ensure the services are documented and that the members who require 2.5hrs of psychotherapy are in compliance with expectations. The Clinical Supervisors will review the expectations in monthly documented supervisions with the Counselors and provide support, direction, and corrections where needed.
The Program Manager is responsible to review the trackers weekly and address concerns with the Clinical Supervisors and Counselors.
The Division Director is responsible to monitor this process.
CORPORATE QUALITY ASSURANCE DEPARTMENT:
The QA Director and designated QA staff will facilitate a bi-monthly review of our approved plans of correction to determine if the program is in compliance. The QA staff observations will be presented and discussed in a QA / Management bi-monthly meeting. A plan will be put in place to identify any barriers and immediately address any lack of compliance issues. All meetings will be documented. The first meeting will be scheduled for September 18, 2024.
Responsible Staff: Corporate QA Manager and Division Director
Effective: 7/3/2024 |