INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ACCE & Associates LLC dba Recovery Works-PA 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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704.11(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 one applicable employee received a minimum of 6 hours of HIV/AIDS using a Department approved curriculum within the regulatory timeframe.
Employee # 1 has been in the position of Project Director since June 20, 2022 and was due to have the communicable disease trainings no later than June 20, 2024. However, the HIV/AIDS training was not documented as complete until January 24, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HIV training that was cited for Employee #1 was already completed at the time of the inspection. No other trainings are required for this employee. To ensure all other employees complete their trainings on time the following monitoring procedures have been established:
Project Director and HR manager now use the Microsoft Planner application for all new and current employees to auto alert a quarterly training progress review and sign off. Planner is a project management application that assigns, tracks, and documents when tasks, such a trainings, are completed or pending. The information is shared across assigned team members and linked to the HR Share Point to centralize the data.
Each employee has been added in the Planner application, assigned to the trainings tasks and is now monitored using this tracking process. Automated quarterly review alerts have been assigned to the Project Director and HR manager for each employee. Upon receiving the quarterly review alert, all three staff members will review the employee's training folder to determine the status of completed and pending trainings, and then use the link to Microsoft Forms application to verify/document that monitoring has occurred.
The Forms application allows the user to complete an electronic form to enter the most recent data regarding their training completion status and needs. It includes a section the requires a plan for completing the required trainings by the due date. Form data is digitally tracked and connected to each user who submits the form and is visible to all parties in an excel spreadsheet. Additionally, when a form is submitted the Project Manager receives an email for another method of monitoring confirmation. This process allows three points of cross-referencing for each employee to ensure compliance and monitoring has occurred. When needed, the Project Manager will work with an employee to review their progress and find the required trainings before the due date.
The Form referred to above was created on 2/20/25 and includes the following required prompts: Date of the employee's training folder review, mandatory training due date, identification of trainings pending completion, and a plan for scheduling the pending trainings. The data from the form is linked to each employee's HR file on Share Point. Each employee who has onboarded less than a year ago has been added to the training review alert plan. All staff members will complete a read and sign of this new procedure by 3/3/2025
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room, as a group session in Group Room 1 was being conducted with the door open and could be seen outside of the group room at 11:40 a.m. on February 7, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff members will read and sign a review of confidentiality procedures on 3/3/25. To address the temperature and reason for the door being ajar, a fan will be placed in the group room and can be used when the temperature is warm. If needed, the group can relocate to another group room with a lower temperature. Project Director will do random checks once per week to observe if the door is closed while group is being facilitated. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on February 7, 2025, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The tag on the fire extinguisher in the rear hallway indicated that the most recent inspection and approval occurred in January 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director contacted the landlord and the fire extinguisher servicing company is scheduled to be onsite and inspect the extinguisher on 3/4/25. Project Director has set a calendar reminder for Jan 2, 2026 to schedule the inspection with the landlord. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of five personnel records, the facility failed to ensure that staff was instructed in the use of the fire extinguishers upon employment in four records reviewed.
Employee # 2 has been in the position of counselor since August 9, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until January 9, 2025.
Employee # 3 has been in the position of counselor since November 25, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until January 9, 2025.
Employee # 4 has been in the position of counselor since August 5, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until January 9, 2025.
Employee # 5 has been in the position of counselor since November 10, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until January 9, 2025.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
HR Manager and Project Director added Fire Safety Training to the New Employee Checklist. The check list has been added to the Planner Application and the task will be assigned to the employee, HR Manager and Project Director. This will send and automated email and require an acknowledgment of the task completion. Project Manager will ensure the task is completed within one week of hire by reviewing the HR folder on or before 1 weeks of the start date. HR Manager will read and sign off on the plan of correction on 3/10/25. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of five personnel records, the facility failed to ensure that four applicable staff members were trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 2 has been in the position of counselor since August 9, 2024 and is current in that position. Employee # 2 began working shifts on August 9, 2024, but was not trained to perform assigned tasks during emergencies until January 9, 2025.
Employee # 3 has been in the position of counselor since November 25, 2024 and is current in that position. Employee # 3 began working shifts on November 25, 2024, but was not trained to perform assigned tasks during emergencies until January 9, 2024.
Employee # 4 has been in the position of counselor since August 5, 2024 and is current in that position. Employee # 4 began working shifts on August 5, 2024, but was not trained to perform assigned tasks during emergencies until January 9, 2025.
Employee # 5 has been in the position of counselor since November 10, 2024 and is current in that position. Employee # 5 began working shifts on November 10, 2024, but was not trained to perform assigned tasks during emergencies until January 9, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
HR Manager and Project Director added Emergency Response Training to the New Employee Checklist. The check list has been added to the Planner Application and the task will be assigned to the employee, HR Manager and Project Director. This will send and automated email and require an acknowledgment of the task completion. Project Manager will ensure the task is completed within two weeks of hire by reviewing the HR folder on or before 2 weeks of the start date. HR Manager will read and sign off on the plan of correction on 3/3/25. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to document that the project director prepared, annually updated and signed a written manual delineating project policies and procedures. The last director signature was completed in 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/16/25 Project Director created a Microsoft Form to use to document incidents of policy updates and annual review. The Form is in the department Policy and Procedures Share Point folder. To ensure it is completed annually, an ongoing annual alert was assigned to the Program Director in the Planner app. The Form's response/digital signature summary is also pinned in the Share Point folder. |
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 eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 1 was admitted on June 20, 2024 and was discharged on September 2, 2024. The record contained documentation of a disclosure of information to a government agency on June 24, 2024, however, the record did not contain a client signed consent to release information form to the agency.
Client # 2 was admitted on August 22, 2024 and was discharged on December 7, 2024. The consent to release information form to the funding source was not signed until October 16, 2024; however, there was evidence of billing prior to the client signed consent to release information form. Additionally, the record contained documentation of a disclosure of information to a government agency on August 30, 2024, however, the record did not contain a client signed consent to release information form to the agency.
This is a repeat citation from the February 20, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/10/25 All program ROIs were updated and modified so they can be completed and included in the intake documents that are sent at admission. An ROI for DHS was created and included with the update documents. These documents are reviewed at admission and will be reviewed by staff members at the intake. All clients requiring an updated ROI(s) will be completed by 3/7/25. The staff members reviewed this verbally and will complete a read and sign on 3/3/25. Project Director will complete random monthly chart audits to ensure ROI compliance. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that a client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment, in seven of seven applicable records reviewed.
Client # 1 was admitted on June 20, 2024 and was discharged on September 2, 2024.
Client # 2 was admitted on August 22, 2024 and was discharged on December 7, 2024.
Client # 4 was admitted on June 17, 2024 and was discharged on November 16, 2024.
Client # 5 was admitted on June 24, 2024 and was discharged on September 18, 2024.
Client # 6 was admitted on September 23, 2024 and was active at the time of the inspection.
Client # 7 was admitted on October 2, 2024 and was active at the time of the inspection.
Client # 8 was admitted on August 6, 2024 and was active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/16 the Client Rights intake document was updated to include the required statements related to retaining civil rights. This form is now being used. Staff members will complete a read and sign for this process on 3/3/25. This form is programmed to be automatically sent with intake consents and no other versions exist. Project Director will complete random monthly chart audits to ensure the form is sent.
Staff members will resend the updated Client Rights via the client portal to all their active members of their caseload by 3/10/25 |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that the project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record, in seven of seven applicable records reviewed.
Client # 1 was admitted on June 20, 2024 and was discharged on September 2, 2024.
Client # 2 was admitted on August 22, 2024 and was discharged on December 7, 2024.
Client # 4 was admitted on June 17, 2024 and was discharged on November 16, 2024.
Client # 5 was admitted on June 24, 2024 and was discharged on September 18, 2024.
Client # 6 was admitted on September 23, 2024 and was active at the time of the inspection.
Client # 7 was admitted on October 2, 2024 and was active at the time of the inspection.
Client # 8 was admitted on August 6, 2024 and was active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/16 the Client Rights intake document was updated to include the required statements related to retaining civil rights. This form is now being used. Staff members will complete a read and sign for this process on 3/10/25. This form is programmed to be automatically sent with intake consents and no other versions exist. Project Director will complete random monthly chart audits to ensure the form is sent. Client #8 is no longer active.
All active clients will have received the updated Clients Right on or before 3/12/25 via the client portal from their counselor or another staff member.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to include documentation of all the required client rights, including that clients have the right to appeal a decision limiting access to their records to the director, in seven of seven applicable records reviewed.
Client # 1 was admitted on June 20, 2024 and was discharged on September 2, 2024.
Client # 2 was admitted on August 22, 2024 and was discharged on December 7, 2024.
Client # 4 was admitted on June 17, 2024 and was discharged on November 16, 2024.
Client # 5 was admitted on June 24, 2024 and was discharged on September 18, 2024.
Client # 6 was admitted on September 23, 2024 and was active at the time of the inspection.
Client # 7 was admitted on October 2, 2024 and was active at the time of the inspection.
Client # 8 was admitted on August 6, 2024 and was active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/16 the Client Rights intake document was updated to include the required statements related to clients having the right to appeal a decision made regarding limiting access to their record. This form is now being used. Staff members will complete a read and sign for this process on 3/10/25. This form is programmed to be automatically sent with intake consents and no other versions exist. Project Director will complete random monthly chart audits to ensure the form is sent. Client #8 is no longer active.
Staff members will resend the updated Client Rights via the client portal to all their active members of their caseload by 3/10/25 |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to document disclosure to the client of criteria for completion in seven of seven applicable records reviewed.
Client # 1 was admitted on June 20, 2024 and was discharged on September 2, 2024.
Client # 2 was admitted on August 22, 2024 and was discharged on December 7, 2024.
Client # 4 was admitted on June 17, 2024 and was discharged on November 16, 2024.
Client # 5 was admitted on June 24, 2024 and was discharged on September 18, 2024.
Client # 6 was admitted on September 23, 2024 and was active at the time of the inspection.
Client # 7 was admitted on October 2, 2024 and was active at the time of the inspection.
Client # 8 was admitted on August 6, 2024 and was active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/16 the Welcome Guide intake document was updated to include the criteria for completion. This form is now being used. Staff members will complete a read and sign for this process on 3/10/25. This form is programmed to be automatically sent with intake consents and no other versions exist. Project Director will complete random monthly chart audits to ensure the form is sent.
Staff members will review the updated Welcome Guide in individual and/or group sessions with all their active members of their caseload by 3/10/25 |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type of treatment and rehabilitation services on the individual treatment and rehabilitation plan in seven of seven applicable records reviewed.
Client # 1 was admitted on June 20, 2024 and was discharged on September 2, 2024. The individual treatment and rehabilitation plan was completed on June 27, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services.
Client # 2 was admitted on August 22, 2024 and was discharged on December 7, 2024. The individual treatment and rehabilitation plan was completed on September 4, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services.
Client # 4 was admitted on June 17, 2024 and was discharged on November 16, 2024. The individual treatment and rehabilitation plan was completed on June 24, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services.
Client # 5 was admitted on June 24, 2024 and was discharged on September 18, 2024. The individual treatment and rehabilitation plan was completed on July 1, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services.
Client # 6 was admitted on September 23, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 23, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services.
Client # 7 was admitted on October 2, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 15, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services.
Client # 8 was admitted on August 6, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 19, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.
These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/16, Project Director updated the initial and Updated treatment plans to include a required drop down box indicating the type of treatment and rehabilitation services recommended for the client. This plan has gone into immediate use. Because the drop down box is required, there is no way to sign and complete the plan without selecting an option. Project Director will do random chart audits to ensure the plans are completed within the compliance standard.
Staff members will complete a read and sign for this new procedure on 3/10/25 |
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 are reviewed and updated at least every sixty days in two of five applicable records reviewed.
Client # 3 was admitted on December 22, 2023 and was discharged on September 18, 2024. A treatment plan update was completed on February 29, 2024, and the next treatment plan update was due no later than April 29, 2024; however, no additional treatment plan updates were completed prior to discharge.
Client # 7 was admitted on October 2, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 15, 2024, and the treatment plan update was due no later than December 14, 2024; however, the treatment plan update was not completed until December 17, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This finding had an internal response procedure that was implemented about one month prior to the audit. The Planner application alerts staff members when a plan will be due within that week. This will remain in place and Project Director will complete random chart audits to ensure plans on the week's "to do" list are completed and that staff members are using the application to remind of tasks due. The treatment plan was also relocated to a tab making checking for compliance faster and more forward facing for the clinicians.
Staff members will complete a read and sign to reinforce the procedure on 3/10/25 |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in four of four applicable records reviewed. The facility policy manual indicates that case consultation notes will be completed quarterly for the first year of treatment.
Client # 2 was admitted on August 22, 2024 and was discharged on December 7, 2024. The first case consultation note was due to be documented by November 20, 2024; however, it was not documented until December 3, 2024.
Client # 6 was admitted on September 23, 2024 and was active at the time of the inspection. The first case consultation note was due to be documented by December 22, 2024; however, the record did not contain documentation of case consultation notes.
Client # 7 was admitted on October 2, 2024 and was active at the time of the inspection. The first case consultation note was due to be documented by December 31, 2024; however, it was not documented until February 6, 2025.
Client # 8 was admitted on August 6, 2024 and was active at the time of the inspection. The first case consultation note was due to be documented by November 4, 2024; however, it was not documented until February 6, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This finding had an internal response procedure that was implemented about one month prior to the audit. The Planner application alerts staff members when a case consultation will be due within that week. This will remain in place and Project Director will complete random chart audits to ensure plans on the week's "to do" list are completed and that staff members are using the application to remind of tasks due. The case consultation was also updated on 2/16 with features that make form completion more efficient and it was relocated to a tab making checking for compliance faster and more forward facing for the clinicians.
Staff members will complete a read and sign to reinforce the procedure on 3/10/25 |
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 ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in one of one applicable record reviewed.
Client # 3 was admitted on December 22, 2023 and was discharged on September 18, 2024. The client record did not contain documentation of a completed aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/16 the discharge form was reviewed and updated to ensure the aftercare plan is a required form element for completion. The form cannot be submitted without the aftercare plan being acknowledged. The form was also updated in a tab that is forward facing to the clinicians, and makes compliance confirmation easier. The project Director will complete random chart audits for discharge summaries to ensure the aftercare plan is complete. Staff will use the chat feature to communicate when a discharge is complete and ready for review as another compliance guardrail.
Staff will complete a read and sign for this updated procedure on 3/10/25 |
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 ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary, in two of five applicable records reviewed.
Client # 3 was admitted on December 22, 2023 and was discharged on September 18, 2024. The record did not contain a discharge summary.
Client # 5 was admitted on June 24, 2024 and was discharged on September 18, 2024. The record did not contain a discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will co-sign discharges to ensure they have been completed following compliance guidelines. Project director will complete random chart audits of closed charts to ensure they have met compliance standards.
Staff members will complete a read and sign to review this procedure update on 3/10/25 |
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 ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in five of five applicable records reviewed.
Client # 1 was admitted on June 20, 2024 and was discharged on September 2, 2024. The record did not contain documentation of follow-up information.
Client # 2 was admitted on August 22, 2024 and was discharged on December 7, 2024. The record did not contain documentation of follow-up information.
Client # 3 was admitted on December 22, 2023 and was discharged on September 18, 2024. The record did not contain documentation of follow-up information.
Client # 4 was admitted on June 17, 2024 and was discharged on November 16, 2024. The record did not contain documentation of follow-up information.
Client # 5 was admitted on June 24, 2024 and was discharged on September 18, 2024. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/16 a discharge follow up letter was created and included in the EMR for staff members to complete and send in the client portal for discharged clients. It includes their last day of treatment, how to re-engage in treatment and community resources for Del aware County Warmline and Crisis services if needed. The letter is sent by the Project Director and will be monitored with monthly review of the discharge list and cross checking that each case was closed with the follow up letter.
Staff members will complete a read and sign regarding this procedure on 3/10/25 |