INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on July 30-31, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Medmark Treatment Centers Washington 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 applicable personnel records, the facility failed to ensure that each counselor met the qualifications of the position at the time of hire in in two of four records.
Staff #2 was hired as a counselor on May 2, 2024 and did not meet the educational requirements to be a counselor.
Staff #3 hired as a counselor on May 6, 2024 and did not meet the educational requirements to be a counselor.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Upon receiving applications for Counselors, Treatment Center Director and Counselor Supervisor will request transcripts and degree from candidates. Treatment Center Director and Counselor Supervisor will ensure that the candidate's educational requirements match that of the regulations before moving forward with the hiring process. All candidates will meet the educational requirements before being hired at this facility. Current Counselors job title will change to Counselor Assistant and Counselor Supervisor will provide the required direct observation for each individual. |
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 provide written individual training plans that were developed with input from both the employee and the supervisor in all records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When creating a training plan, Treatment Center Director or Supervisor and the employee will sign to acknowledge that the training plan was developed together. Training plans will be developed annually. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill logs from September 2023 to April 2024, the facility failed to maintain a written fire drill record that included the exit route utilized at the time of the drill for September 2023-April 2024 fire drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After completing monthly fire drills, the Treatment Center Director will document the exit route used on the drill report form. Treatment Center Director will ensure that all requirements are reflected on the drill report each month. |
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
Based on review of the facility policy and procedure manual, the facility failed to provide documentation of the project director preparing, annually updating, and signing a written manual delineating project policies and procedures. The policy and procedure manual was not annually updated by signature since 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency has been corrected since inspection. Moving forward, Treatment Center Director will provide a signature next to annual update and state if the policies and procedures have been updated/no changes. Treatment Center Director will complete by signing on document annually. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on a review of patient records, the facility failed to contact the previous facility for the treatment history in one of one applicable records. The accepting facility must attempt to contact the previous facility when admitting a patient previously discharged from treatment at another narcotic treatment program.
Patient #2 was transferred from another narcotic treatment program and admitted on July 9, 2024 and was still active at the time of the inspection. The patient's record did not have documentation that the facility attempted to contact the previous facility for the patient's treatment history.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
When a transfer patient is admitted to the program, Counselors will document their attempts when requesting transfer paperwork. Counselors will also send a notice of transfer to previous clinic and upload to patient's chart. Counselor Supervisor will conduct an audit after the completion of all intakes to ensure that paperwork has been requested and uploaded to the patient's chart. Nursing staff will document a dose verification of patient transferring to this program. If the program is unable to retain transfer paperwork from patient's previous facility, the patient's psychotherapy and privilege level will be that of a new admission. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records and a review of the facility's policies and procedure that states a picture will be taken and added to the electronic record at intake, the facility failed to update client photographs every three years in two out of eleven patient records.
Patient #2 was admitted on July 9, 2024 and was still active at the time of the inspection. The patient record failed to include a picture taken at intake and the patient's photo ID located in the record was dated February 27, 2021 making it more than three years old.
Patient #4 was admitted on May 29, 2024 and was still active at the time of the inspection. The patient record failed to include a picture taken at intake and the patient's photo ID located in the record was dated June 20, 2020 making it more than three years old.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon admission, front desk receptionist and patient access representative will take the patient's photo and upload to patient's chart with signed consent. Upon completion of intake, staff will provide intake checklist to Treatment Center Director. Treatment Center Director will review for accuracy to ensure that the patient intake photo is uploaded to chart. Treatment Center Director, front desk receptionist and patient access representative will go through each patient's chart to ensure that a photo has been uploaded in the past 3 years. Photos will be uploaded for charts that are incomplete. |
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 the review of patient records, the facility failed to complete random drug-screening urinalysis at least monthly in two out of eight patient records.
Patient # 8 was admitted on August 16, 2022 and was discharged on May 10, 2024. There was no documentation of a urinalysis done in April 2024.
Patient #9 was admitted on January 31, 2024 and was still active at the time of the inspection. There was no documentation of a urinalysis done in May and June 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This deficiency has been corrected. Treatment Center Director spoke with the IT department to correct the issue following the inspection. Nursing department and medical assistant will monitor urinalysis to ensure that each patient completed a urinalysis each month. Nursing department and medical assistant will place a UA hold for any patient whose UA hold failed to autogenerate. Nursing department will report concerns to Treatment Center Director. Treatment Center Director will monitor on a monthly basis. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to follow federal and state statutes and regulations regarding initial dose in one of four records.
Patient #1 was admitted on June 25, 2024 and was still active at the time of the inspection. The patient's initial order and dose was 140mg.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a patient is being admitted into the program, physician will evaluate patient to determine patient's initial dose. Treatment Center Director provided training to medical staff on the procedure for initial dose regulations. Treatment Center Director will conduct an audit after every intake moving forward. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician determine the patient ' s initial in two of four applicable records.
Patient #1 was admitted on June 25, 2024 and was still active at the time of the inspection. The facility was the receiving narcotic treatment program and did not confirm the patient ' s previous dose history prior to writing the order. The patient ' s record indicated that the initial dose order was written by the facility ' s physician ' s assistant.
Patient #2 was transferred from another narcotic treatment program on July 9, 2024 and was still active at the time of the inspection. The facility was the receiving narcotic treatment program and did not confirm the patient ' s previous dose history prior to writing the order. The patient ' s record indicated that the initial dose order was written by the facility ' s physician ' s assistant.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
When a patient is being admitted into the program, physician will evaluate patient to determine patient's initial dose. Treatment Center Director provided training to medical staff on the procedure for initial dose regulations. If a patient is transferring from another facility, nursing staff will document dose verification and communicate dose to physician prior to order being written. Clinic staff will document transfer paperwork requests in the patient's chart.If a transfer patient's previous treatment history cannot be confirmed by receiving transfer paperwork, patient will counseling level and privilege level will be that of a new admission. Treatment Center Director will conduct an audit after every intake moving forward. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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 patients with one hour per month of therapy during the third and fourth year of treatment in two out of three applicable records.
Patient #5 was admitted on May 24, 2022 and was still active at the time of the inspection. The patient received 0 hours of psychotherapy for June 2024.
Patient #9 was admitted on January 31, 2024 and was still active at the time of the inspection. The patient's record documented two years of previous treatment at another facility. The patient received 0 hours of psychotherapy for May and June 2024.
This finding was reviewed with facility staff during the licensing inspection.
This is a repeat citation from the March 27, 2024 and August 9, 2023 licensing inspections.
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Plan of Correction
Counselors will schedule psychotherapy according to the patient's length of time in treatment. Counselors will document missed appointments, if they occur, and reschedule the patient for psychotherapy. Counselor Supervisor will audit psychotherapy sessions on a weekly basis and at the end of the month. Counselor Supervisor will run the patients unseen report and distribute to all Counselors on a weekly basis. Counselors will inform Counselor Supervisor of when the psychotherapy is scheduled to take place. Counselor Supervisor will report status to Treatment Center Director. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. 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 patients with one hour every two months of therapy during the 4+ year of treatment in two out of two applicable records.
Patient #6 was admitted on July 24, 2020 and transferred to another facility July 1, 2024. Documentation in patient record indicates prior treatment history. The patient has not received any psychotherapy hours since March 19, 2024.
Patient #11 was admitted on May 3, 2016 and was still active at the time of the inspection. The patient received 0 hours of psychotherapy since November 28, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors will schedule psychotherapy according to the patient's length of time in treatment. Counselors will document missed appointments, if they occur, and reschedule the patient for psychotherapy. Counselor Supervisor will audit psychotherapy sessions on a weekly basis and at the end of the month. Counselor Supervisor will run the patients unseen report and distribute to all Counselors on a weekly basis. Counselors will inform Counselor Supervisor of when the psychotherapy is scheduled to take place. Counselor Supervisor will report status to Treatment Center Director. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to document transfer of patient files to the patient's new treatment facility in one out of one applicable record.
Patient #6 was admitted on July 24, 2020 and transferred to another facility on July 1, 2024. At the time of the inspection, there was no documentation that facility transferred patient files to the new facility.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
When a patient transfers from this program to another facility, the patient's Counselor will send patient records to the transferring facility. Counselor Supervisor will monitor all discharges of patients who transferred to ensure that the patient's chart includes documentation that the transfer paperwork has been sent to new facility and uploaded to the patient's chart. All staff with document communications with new facility. Counselor Supervisor will monitor by checking the discharge checklist that the Counselor completes after a patient has been discharged. If the Counselor indicates that the patient transferred to a new facility, Counselor Supervisor will audit the patient's chart to ensure that transfer paperwork is complete on the day the patient was discharged from the program. Counselors will alert Counselor Supervisor of discharge and provide discharge checklist to Counselor Supervisor when completed.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to provide, in writing, documentation that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in one of one applicable records.
Patient #2 was transferred from another narcotic treatment program on July 9, 2024 and was still active at the time of the inspection. The patient ' s record did not have documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
When a patient transfers from this program to another, this program will inform new facility of intended transfer. Nursing staff will confirm patient's dosage level.
Counselor will complete a notice of transfer and send to transfer facility. Counselor will send patient's record and documentation. Counselor will upload all documentation to patient's chart, including the attempt(s) to send the necessary documents. Counselor Supervisor will monitor transfer patients (discharges) by following the discharge checklist completed by the Counselor. Discharge checklist indicates the reason for discharge. Counselor Supervisor will ensure that all documentation in the chart is uploaded and accurate. Counselor Supervisor will provide training to clinical staff on transfer paperwork on 10/3/24. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to document an annual clinical evaluation within the regulatory timeframe in two out of four applicable records.
Patient #5 was admitted on May 24, 2022 and was still active at the time of the inspection. The annual clinical evaluation was due on May 3, 2024; however, it was completed on July 29, 2024.
Patient #11 was admitted on May 3, 2016 and was still active at the time of the inspection. The annual clinical evaluation was due on May 2, 2024; however, it was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the March 27, 2024 and August 9, 2023 licensing inspections.
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Plan of Correction
Counselors must complete clinical annuals prior to their due date. Counselors will track their patient's annual due dates appropriately and complete within timeframe. Counselor Supervisor will audit caseloads on a monthly basis to ensure completion in a timely manner. Counselor Supervisor will run reports on the EMR to determine upcoming annual due dates and verify completion. Counselor Supervisor will ensure that annuals are completed on time by utilizing EMR reports and will communicate a reminder to clinical staff of upcoming due dates. Counselor Supervisor will provide training to clinical staff on October 3, 2024. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of applicable client records, the facility failed to document proposed type of support service on individual treatment plans in one of three records.
Client #2 was admitted on July 9, 2024 and was still active at the time of the inspection. The treatment plan was dated July 9, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Counselors will be responsible for documenting the patient's supportive services in the patient's treatment plan. When the Counselor Supervisor is signing treatment plans, Supervisor will ensure that supportive services is listed on the treatment plan. Counselor Supervisor will inform Counselor if supportive services is not listed on the treatment plan and review for correction and completion.
Counselor Supervisor will conduct documentation training on October 3, 2024 for the clinical staff. |
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 document treatment plan updates every sixty days in six out of nine client records reviewed.
Client #5 was admitted on May 24, 2022 and was still active at the time of the inspection. A treatment plan update was completed on May 6, 2024 and the next update was due no later than July 6 2024; however, it was not completed until July 29, 2024.
Client #6 was admitted on July 24, 2020 and transferred to another facility July 1, 2024. A treatment plan update was completed on February 5, 2024 and the next update was due no later than April 5, 2024; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted on June 9, 2023 and was discharged on June 5, 2024. A treatment plan update was completed on March 21, 2024 and the next update was due no later than May 21, 2024; however, there was no update documented in the record at the time of the inspection.
Client #8 was admitted on August 16, 2022 and was discharged on May 10, 2024. A treatment plan update was completed on January 17, 2024 and the next update was due no later than March 17, 2024; however, there was no update documented in the record at the time of the inspection.
Client #9 was admitted on January 31, 2024 and was still active at the time of the inspection. A treatment plan update was completed on April 1, 2024 and the next update was due no later than June 1, 2024; however, there was no update documented in the record at the time of the inspection.
Client #11 was admitted on May 3, 2016 and was still active at the time of the inspection. A treatment plan update was completed on January 25, 2024 and the next update was due no later than March 25, 2024; however, there was no update documented in the record until May 8, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors are responsible for tracking and completing treatment plans by their due date. Counselors will develop a tracking system that shows when a treatment plan review is upcoming. Counselor Supervisor will utilize the treatment plan tracker in the EMR system to track upcoming and completed treatment plans. Counselor Supervisor will provide documentation training to the clinical staff on October 3, 2024 to address timeliness of treatment plan reviews. |
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 applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in two of five applicable records. The facility policy and procedure manual indicate a case consultation to occur every thirty days for the first year of treatment, then annually thereafter.
Client #9 was admitted on January 31, 2024 and was still active at the time of the inspection. A case consultation was not completed for May and June 2024 at the time of the inspection.
Client #11 was admitted on May 3, 2016 and was still active at the time of the inspection. A case consultation has not been completed since April 23, 2021.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the March 27, 2024 and August 9, 2023 licensing inspections.
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Plan of Correction
Clinical staff will be trained on case consultations, including the timely completion of them during a clinical staff meeting to be held on October 3, 2024. Clinical staff will complete case consultations within the appropriate timeframe. Counselor Supervisor will audit the completion of case consultations by utilizing reports from the EMR system. Counselor Supervisor will continue to complete chart audits on a monthly basis and train clinical staff on required documentation. |
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 client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for completing case consultations per the facility ' s policy and procedure manual was submitted and approved by the Department for the March 27, 2024 and August 9, 2023 licensing inspections. Case consultations were again found to be a deficiency in the July 30-31, 2024 annual licensing inspection.
A plan of correction for the completion of annual clinical evaluations was submitted and approved by the Department for the March 27, 2024 and August 9, 2023 licensing inspections. The completion of annual clinical evaluations was again found to be a deficiency in the July 30-31, 2024 annual licensing inspection.
A plan of correction for failing to ensure that patients receive one hour of psychotherapy per month during the patient's third and fourth years of treatment was submitted and approved by the Department for the March 27, 2024 and August 9, 2023 licensing inspections. The amount of counseling hours for patient's during their third and fourth years of treatment was again found to be a deficiency in the July 30-31, 2024 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 27, 2024 and August 9, 2023 licensing inspections.
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Plan of Correction
Treatment Center Director, Regional Director of Operations and Counselor Supervisor will comply with plans of correction and inform staff of plans of correction. Treatment Center Director and Counselor Supervisor will audit patient charts monthly to ensure that case consultations, clinical annuals and psychotherapy are in compliance and completed in a timely manner. |