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Home My WebLink About2016-08-08 16-290 Council Documents (3) car f INTERNATIONAL "V) Excel\ 'aC ■ car . 111 * ACCREDITED ■ Three-Year Accreditation ■ ■ ■ CARF ■ Survey Report ■ ■ for ■ Colonial Management ■ Group, LP dba ■ ■ Penobscot Metro ■ Treatment Center ■ CARIFEIT 71ONAL CAEI-0014 CAW CANADA $051 bstlovelsokt Road Mat*Weed A NW34101410 140010020101A*vsm*tlw .0C 20036 USA 5401.04‘411513432 emu 345414.851$21a 0831 24800s886 1122 3414re.0714345444 30/11Y5203251044 111202•017 7017804292538 5203111128 F282$87 Re Fax 7804261274 car f INTERNATIONAL ■ ' tee,, 404.1 Organization Qt 111Colonial Management Group,LP dba Penobscot Metro Treatment Center 4t car 4. 659 Hogan Road * ACCREDITED 41, ■ Bangor,ME 04401 Organizational Leadership ■ Mike Ford,LCDC Three-Year Accreditation Director of Accreditation&Corporate Compliance ■ Terri L. Senkow Licensing Coordinator ■ Survey Dates October 18-19,2012 ■ Survey Team Michael J. O'Malley,Ph.D.,Administrative Surveyor IIChristine E. Miller,Ph.D.,Program Surveyor ■ Programs/Services Surveyed Outpatient Treatment: Opioid Treatment Program (Adults) ■ Previous Survey October 5-6,2009 ■ Three-Year Accreditation ■ Survey Outcome ■ Three-Year Accreditation Expiration:November 2015 1 ■ ■ ■ CAW MIER4110ML CARE-QCAC CAEF CANADA OM fat Rod sno fitiodohind/awls,NW,-9991410 teoo•r0020IOU kienaNW Two*,AZ 86768 USA WohtnieentAC 20036 USA EdNotat,AB TJ3o2:CANAOA 904 4419,8291 104419e1186SW 1122 9**e48774346444 ievITY 520 ,s044 1e12 587500f RI7804 2539 Pax 520318 Y 24 P 2036878009 /8042472714 SURVEY SUMMARY Colonial Management Group, LP dba Penobscot Metro Treatment Center has strengths in many areas. • Penobscot Metro Treatment Center is committed to delivering quality outpatient methadone treatment services. Persons served are key members of its treatment team. • The regional director and program director lead by example as they routinely demonstrate Colonial Management Group's commitment to quality,person-centered care.They are passionate, caring individuals working hard to ensure that persons served and staff members are successful. ■ Administrative and clinical staff members are committed to treating persons served with empathy,dignity,and respect. ■ Penobscot Metro Treatment Center is a valuable community asset to Bangor,Maine,and the surrounding area. It has an extensive networking database and access to community resources. Staff members know their community and resources and work diligently to maintain strong relationships with family service organizations,housing and employment resources,and the offices of children's services and juvenile justice. • Family members and persons served report they are very pleased with the organization. One person served stated, "I feel like everybody there wants to help me." • Penobscot Metro Treatment Center has a pool of counselors who are well trained and committed to developing quality clinical outcomes based on the goals of persons served. • Penobscot Metro Treatment Center has a focus on improving the retention of those served. Staff members implemented a 30-day program in which persons served contact their counselor every day for 30 days to pick up their identification cards and meet with their counselor to discuss treatment progress. The absenteeism rate dropped from 9 percent to 4.8 percent as of September 2012. • Treatment staff members write thorough interpretive summaries that are part of the assessment. The summaries include key components from the assessment;a review of the person's strengths, needs,abilities,and preferences;and recommendations for the treatment plan. In the following area Penobscot Metro Treatment Center demonstrates exemplary conformance to the standards. • Penobscot Metro Treatment Center is commended for providing outstanding advocacy on behalf of persons served.The program director speaks regularly with a wide variety of public and private organizations, service groups,and individuals for the purpose of educating them about methadone and other opiate treatment methodologies, clarifying the recovery process and the language of recovery,and performing outreach to break down the stigma that accompanies methadone treatment. cad. INTERNATIONAL Page 29l ricin PSQPJE'S LIVES Penobscot Metro Treatment Center should seek improvement in the areas identified by the recommendations in the report. Consultation given does not indicate nonconformance to standards but is offered as a suggestion for further quality improvement. On balance,Penobscot Metro Treatment Center has made a dedicated effort to maintain international accreditation and demonstrated substantial conformance to CARF standards. The organization provides excellent outpatient opiate treatment services and has support and cooperation from its referral sources. Persons served and referral sources have all expressed satisfaction with services provided. Staff members are committed to the provision of quality care and continuous improvement. Penobscot Metro Treatment Center has the human resources and support needed to address the recommendations detailed in this report. It also has the ability to grow and change to meet the various challenges that affect the individuals it serves. Colonial Management Group,LP dba Penobscot Metro Treatment Center has earned a Three-Year Accreditation. Colonial Management Group's regional director and Penobscot Metro Treatment Center's program director and staff members are congratulated for this accomplishment and encouraged to continue using CARF standards as guidelines for continuous quality improvement. SECTION 1 . ASPIRE TO EXCELLENCE® A. Leadership Principle Statement CARF-accredited organizations identify leadership that embraces the values of accountability and responsibility to the individual organization's stated mission.The leadership demonstrates corporate social responsibility. Key Areas Addressed • Leadership structure • Leadership guidance • Commitment to diversity • Corporate responsibility • Corporate compliance Recommendations There are no recommendations in this area. car I INTERNATIONAL Page 3 enhancing PEOPLE'S LIVES Exemplary Conformance A.6.d. Penobscot Metro Treatment Center is commended for providing outstanding advocacy on behalf of persons served. The program director speaks regularly with a wide variety of public and private organizations, service groups, and individuals for the purpose of educating them about methadone and other opiate treatment methodologies,clarifyingprocess and the language of p � the recovery �ag recovery,and performing outreach to break down the stigma that accompanies methadone treatment. C. Strategic Planning Principle Statement CARF-accredited organizations establish a foundation for success through strategic planning focused on taking advantage of strengths and opportunities and addressing weaknesses and threats. Key Areas Addressed ■ Strategic planning considers stakeholder expectations and environmental impacts • Written strategic plan sets goals • Plan is implemented, shared,and kept relevant Recommendations There are no recommendations in this area. D. Input from Persons Served and Other Stakeholders Principle Statement CARF-accredited organizations continually focus on the expectations of the persons served and other stakeholders. The standards in this subsection direct the organization's focus to soliciting, collecting,analyzing,and using input from all stakeholders to create services that meet or exceed the expectations of the persons served,the community,and other stakeholders. cat f INTERNATIONAL Page 4 enhancing PEOPLE'S LIVES Key Areas Addressed ■ Ongoing collection of information from a variety of sources • Analysis and integration into business practices • Leadership response to information collected Recommendations There are no recommendations in this area. E. Legal Requirements Principle Statement CARF-accredited organizations comply with all legal and regulatory requirements. Key Areas Addressed • Compliance with all legal/regulatory requirements Recommendations There are no recommendations in this area. F. Financial Planning and Management Principle Statement CARF-accredited organizations strive to be financially responsible and solvent, conducting fiscal management in a manner that supports their mission,values,and annual performance objectives. Fiscal practices adhere to established accounting principles and business practices. Fiscal management covers daily operational cost management and incorporates plans for long-term solvency. Key Areas Addressed • Budget(s) prepared,shared,and reflective of strategic planning • Financial results reported/compared to budgeted performance • Organization review • Fiscal policies and procedures car 1 INTERNATIONAL Page 5 enbancing PEOPLE'S LIVES ■ Review of service billing records and fee structure • Financial review/audit • Safeguarding funds of persons served Recommendations F.7.a. through F.7.b.(3) It is recommended that the organization conduct a quarterly review of a representative sample of billing records of persons served to document that dates of services provided coincide with billed episodes of care, determine if bills accurately reflect services rendered,and identify necessary corrective action. G. Risk Management Principle Statement CARF-accredited organizations engage in a coordinated set of activities designed to control threats to their people,property,income,goodwill,and ability to accomplish goals. Key Areas Addressed ■ Identification of loss exposures ■ Development of Risk Management plan ■ Adequate insurance coverage Recommendations There are no recommendations in this area. Consultation ■ It is suggested that Colonial Management Group develop a process that allows for review and analysis of potential loss exposures specific to the Penobscot Metro Treatment Center location. H. Health and Safety Principle Statement CARF-accredited organizations maintain healthy, safe,and clean environments that support quality services and minimize risk of harm to persons served,personnel, and other stakeholders. car 1 INTERNATIONAL Page 6 enticing PEOPLE'S LIVES Key Areas Addressed ■ Inspections ■ Emergency procedures ■ Access to emergency first aid • Competency of personnel in safety procedures ■ Reporting/reviewing critical incidents ■ Infection control Recommendations There are no recommendations in this area. I. Human Resources Principle Statement CARF-accredited organizations demonstrate that they value their human resources. It should be evident that personnel are involved and engaged in the success of the organization and the persons they serve. Key Areas Addressed • Adequate staffing ■ Verification of background/credentials • Recruitment/retention efforts ■ Personnel skills/characteristics ■ Annual review of job descriptions/performance • Policies regarding students/volunteers,if applicable Recommendations There are no recommendations in this area. car I INTERNATIONAL Page 7 enhancing PEOPLE'S LIVES J. Technology Principle Statement CARF-accredited organizations plan for the use of technology to support and advance effective and efficient service and business practices. Key Areas Addressed • Written technology and system plan Recommendations There are no recommendations in this area. K. Rights of Persons Served Principle Statement CARF-accredited organizations protect and promote the rights of all persons served. This commitment guides the delivery of services and ongoing interactions with the persons served. Key Areas Addressed ■ Communication of rights • Policies that promote rights ■ Complaint,grievance,and appeals policy ■ Annual review of complaints Recommendations There are no recommendations in this area. L. Accessibility Principle Statement CARF-accredited organizations promote accessibility and the removal of barriers for the persons served and other stakeholders. cat I INTERNATIONAL Page 8 enhancing PEOPLE'S LIVES Key Areas Addressed ■ Written accessibility plan(s) • Status report regarding removal of identified barriers • Requests for reasonable accommodations Recommendations There are no recommendations in this area. M. Performance Measurement and Management Principle Statement CARF-accredited organizations are committed to continually improving their organizations and service delivery to the persons served. Data are collected and information is used to manage and improve service delivery. Key Areas Addressed • Information collection,use,and management ■ Setting and measuring performance indicators Recommendations There are no recommendations in this area. N. Performance Improvement Principle Statement The dynamic nature of continuous improvement in a CARF-accredited organization sets it apart from other organizations providing similar services. CART-accredited organizations share and provide the persons served and other interested stakeholders with ongoing information about their actual performance as a business entity and their ability to achieve optimal outcomes for the persons served through their programs and services. Key Areas Addressed ■ Proactive performance improvement ■ Performance information shared with all stakeholders Call INTERNATIONAL Page 9 8t2 ncxng PEOPLE'S LIVES Recommendations There are no recommendations in this area. SECTION 2. GENERAL PROGRAM STANDARDS Principle Statement For an organization to achieve quality services,the persons served are active participants in the planning,prioritization,implementation,and ongoing evaluation of the services offered.A commitment to quality and the involvement of the persons served span the entire time that the persons served are involved with the organization. The service planning process is individualized, establishing goals and objectives that incorporate the unique strengths,needs,abilities,and preferences of the persons served.The persons served have the opportunity to transition easily through a system of care. A. Program/Service Structure Principle Statement A fundamental responsibility of the organization is to provide a comprehensive program structure. The staffing is designed to maximize opportunities for the persons served to obtain and participate in the services provided. Key Areas Addressed • Written program plan • Crisis intervention provided • Medical consultation • Services relevant to diversity ■ Assistance with advocacy and support groups • Team duties com osition p / • Relevant education • Clinical supervision ■ Family participation encouraged Cad 1 INTERNATIONAL Page 10 en acing PEOPLE'S LIVES Recommendations A.22.g. Although ongoing supervision of clinical service personnel addresses various clinical and treatment issues,the organization is urged to include cultural competency issues in supervision sessions. Consultation ■ Although documented team meetings occur regularly,it is suggested that the organization structure these meetings to include regular input from the medical director. B. Screening and Access to Services Principle Statement The process of screening and assessment is designed to determine a person's eligibility for services and the organization's ability to provide those services.A person-centered assessment process helps to maximize opportunities for the persons served to gain access to the organization's programs and services. Each person served is actively involved in,and has a significant role in,the assessment process.Assessments are conducted in a manner that identifies the historical and current information of the person served as well as his or her strengths,needs,abilities,and preferences. Assessment data may be gathered through various means including face-to-face contact,telehealth, or written material;and from various sources including the person served, his or her family or significant others,or from external resources. Key Areas Addressed • Screening process described in policies and procedures ■ Ineligibility for services ■ Admission criteria • Orientation information provided regarding rights,grievances, services, fees, etc. • Waiting list ■ Primary and ongoing assessments IN Reassessments Recommendations B.24.m.(3) The assessment should include information about the culture of thep erson served.This section of the assessment was often left blank or had minimal information. call INTERNATIONAL Page 11 enG ng PEOPLE'S LIVES C. Person-Centered Plan Principle Statement Each person served is actively involved in and has a significant role in the person-centered planning process and determining the direction of his or her plan. The person-centered plan contains goals and objectives that incorporate the unique strengths, needs, abilities,and preferences of the person served,as well as identified challenges and potential solutions.The planning process is person- directed and person-centered.The person-centered plan may also be referred to as an individual service plan,treatment plan,or plan of care. In a family-centered program,the plan may be for the family and identified as a family-centered plan. Key Areas Addressed • Development of person-centered plan • Co-occurring disabilities/disorders ■ Person-centeredan P lgoals and objectives ■ Designated person coordinates services Recommendations C.2.b.(7) It is recommended that treatment objectives in the person-centered plan be time specific. Start dates were written without corresponding completion dates. C.8.a.(1)(a) C.8.a.(1)(b) Although progress notes were consistently written following a treatment service,the organization is urged to document progress toward achievement of identified objectives and goals. D. Transition/Discharge Principle Statement Transition, continuing care, or discharge planning assists the persons served to move from one level of care to another within the organization or to obtain services that are needed but are not available within the organization.The transition process is planned with the active participation of each person served.Transition may include planned discharge,placement on inactive status,movement to a different level of service or intensity of contact, or a re-entry program in a criminal justice system. The transition plan is a document developed with and for the person served and other interested participants to guide the person served in activities following transition/discharge to support the gains made during program participation. It is prepared with the active participation of person served when he or she moves to another level of care,after-care program,or community-based call INTERNATIONAL Page 12 enhancing PEOPLE'S LIVES services. The transition plan is meant to be a plan that the person served uses to identify the support that is needed to prevent a recurrence of symptoms or reduction in functioning. It is expected that the person served receives a copy of the transition plan. A discharge summary is a clinical document written by the program personnel who are involved in the services provided to the person served and is completed when the person leaves the program (planned or unplanned). It is a document that is intended for the record of the person served and released,with appropriate authorization,to describe the course of services that the program provided and the response by the person served. Just as the assessment is critical to the success of treatment,the transition services are critical for the support of the individual's ongoing recovery or well-being. The organization proactively attempts to connect the persons served with the receiving service provider and contact the persons served after formal transition or discharge to gather needed information related to their post-discharge status. Discharge information is reviewed to determine the effectiveness of its services and whether additional services were needed. Transition planning may be included as part of the person-centered plan.The transition plan and/or discharge summary may be a combined document as long as it is clear whether the information relates to transition or pre-discharge planning or identifies the person's discharge or departure from the program. Key Areas Addressed • Referral or transition to other services • Active participation of persons served • Transition planning at earliest point ■ Unplanned discharge referrals ■ Plan addresses strengths,needs,abilities,preferences ■ Follow-up for persons discharged for aggressiveness Recommendations There are no recommendations in this area. E. Medication Management Principle Statement These standards address the practice of evaluating,prescribing,and dispensing opioid agonist treatment medications approved by the Food and Drug Administration for use in the treatment of opioid addiction. car I INTERNATIONAL Page 13 enhancing PEOPLE'S LIVES Key Areas Addressed ■ Individual records of medication • Physician review ■ Policies and procedures for prescribing,dispensing, and administering medications ■ Training regarding medications I Policies and procedures for safe handling of medication Recommendations There are no recommendations in this area. F. Medication Use Principle Statement Medication use is the practice of handling,prescribing,dispensing,and/or administering medications to persons served in response to specific symptoms,behaviors,and conditions for which the use of medications is indicated and deemed efficacious. Medication use may include self administration,or be provided by personnel of the organization or under contract with a licensed individual. Medication use is directed toward maximizing the functioning of the persons served while reducing their specific symptoms and minimizing the impact of side effects. Medication use includes prescribed or sample medications, and may,when required as part of the treatment regimen,include over-the-counter or alternative medications provided to the person served. Alternative medications can include herbal or mineral supplements,vitamins,homeopathic remedies,hormone therapy,or culturally specific treatments. Medication control is identified as the process of physically controlling,transporting, storing,and disposing of medications,including those self administered by the person served. Self administration for adults is the application of a medication (whether by injection,inhalation, oral ingestion,or any other means) by the person served,to his/her body;and may include the organization storing the medication for the person served, or may include staff handing the bottle or blister-pak to the person served,instructing or verbally prompting the person served to take the medication, coaching the person served through the steps to ensure proper adherence,and closely observing the person served self-administering the medication. Self administration by children or adolescents in a residential setting must be directly supervised by personnel,and standards related to medication use applied. Dispensing is considered the practice of pharmacy;the process of preparing and delivering a prescribed medication (including samples) that has been packaged or re-packaged and labeled by a physician or pharmacist or other qualified professional licensed to dispense (for later oral ingestion, injection,inhalation,or other means of administration). carr INTERNATIONAL Page 14 enhancing PEOPLE'S LIVES Prescribing is evaluating, what agent is to be used by and giving direction to a person served (or family/legal guardian),in the preparation and administration of a remedy to be used in the treatment of disease. It includes a verbal or written order,by a qualified professional licensed to prescribe, that details what medication should be given to whom,in what formulation and dose,by what route,when,how frequently, and for what length of time. Key Areas Addressed ■ Individual records of medication • Physician review • Policies and procedures for prescribing, dispensing,and administering medications • Training regarding medications • Policies and procedures for safe handling of medication Recommendations There are no recommendations in this area. G. Nonviolent Practices Principle Statement Programs strive to be learning environments and to support persons served in the development of recovery,resiliency,and wellness. Relationships are central to supporting individuals in recovery and wellness. Programs are challenged to establish quality relationships as a foundation to supporting recovery and wellness. Providers need to be mindful of developing cultures that create healing, healthy and safe environments, and include the following: ■ Engagement ■ Partnership—power with,not over ■ Holistic approaches ■ Respect IN Hope P IN Self direction Programs need to recognize that individuals may require supports to fully benefit from their services. Staff are expected to access or provide those supports wanted and needed by the individual. Supports may include environmental supports,verbal prompts,written expectations, clarity of rules and expectations, or praise and encouragement. ca WTERNATiONAL. Pae 15 enhancing g PEOPLE'S LIVES Even with supports,there are times when individuals may show signs of fear,anger,or pain,which may lead to aggression or agitation. Staff members are trained to recognize and respond to these signs through de-escalation, changes to physical environment,implementation of meaningful and engaging activities,redirection,active listening, etc. On the rare occasions when these interventions are not successful and there is imminent danger of serious harm, seclusion or restraint may be used to ensure safety. Seclusion and restraint are never considered treatment interventions; they are always considered actions of last resort. The use of seclusion and restraint must always be followed by a full review,as part of the process to eliminate the use of these in the future. The goal is to eliminate the use of seclusion and restraint in opioid treatment,as the use of seclusion or restraint creates potential physical and psychological dangers to the persons subject to the interventions,to the staff members who administer them,or those who witness the practice. Each organization still utilizing seclusion or restraint should have the elimination thereof as an eventual goal. Restraint is the use of physical force or mechanical means to temporarily limit a person's freedom of movement; chemical restraint is the involuntary emergency administration of medication,in immediate response to a dangerous behavior. Restraints used as an assistive device for persons with physical or medical needs are not considered restraints for purposes of this section. Briefly holding a person served,without undue force, for the purpose of comforting him or her or to prevent self- injurious behavior or injury to self,or holding a person's hand or arm to safely guide him or her from one area to another,is not a restraint. Separating individuals threatening to harm one another, without implementing restraints,is not considered restraint. Seclusion refers to restriction of the person served to a segregated room with the person's freedom to leave physically restricted.Voluntary time out is not considered seclusion,even though the voluntary time out may occur in response to verbal direction; the person served is considered in seclusion if freedom to leave the segregated room is denied. Seclusion or restraint by trained and competent personnel is used only when other less restrictive measures have been found to be ineffective to protect the person served or others from injury or serious harm. Peer restraint is not considered an acceptable alternative to restraint by personnel. Seclusion or restraint is not used as a means of coercion, discipline, convenience, or retaliation. In a correctional setting, the use of seclusion or restraint for purposes of security is not considered seclusion or restraint under these standards.Security doors designed to prevent elopement or wandering are not considered seclusion or restraint. Security measures for forensic purposes, such as the use of handcuffs instituted by law enforcement personnel,are not subject to these standards. When permissible, consideration is made to removal of physical restraints while the person is receiving services in the behavioral health care setting. Key Areas Addressed ■ Training and procedures supporting non-violent practices ■ Policies and procedures for use of seclusion and restraint • Patterns of use reviewed ■ Persons trained in use • Plans for reduction/elimination of use car(INTERNATIONAL Page 16 enhancing PEOPLE'S LIVES Recommendations There are no recommendations in this area. H. Records of the Persons Served Principle Statement A complete and accurate record is developed to ensure that all appropriate individuals have access to relevant clinical and other information regarding each person served. Key Areas Addressed ■ Confidentiality • Time frames for entries to records IN Individual record requirements IN Duplicate records Recommendations There are no recommendations in this area. I. Quality Records Management Principle Statement The organization has systems and procedures that provide for the ongoing monitoring of the quality,appropriateness,and utilization of the services provided.This is largely accomplished through a systematic review of the records of the persons served. The review assists the organization in improving the quality of services provided to each person served. Key Areas Addressed ■ Quarterly professional review • Review current and closed records • Items addressed in quarterly review • Use of information to improve quality of services calf INTERNATIONAL Page 17 enacing PEOPLE`S LIVES • Recommendations I.1.a. through I.1.b.(3) The organization is urged to conduct a quarterly records review of services that documents quality of service delivery,appropriateness of services,and patterns of service utilization. I.2.a. through I.2.c. The organization should verify that the quarterly records review is conducted by trained and qualified personnel. The review should be conducted on a representative sample of current and closed records and in accordance with an established review process. I.4.a.(1)through I.4.j. The quality records review should address whether persons served were provided with an appropriate orientation and actively involved in making informed choices regarding services they received; confidential information was released according to applicable laws/regulations; assessments of persons served were thorough, complete, and timely;actual services reflect appropriate level of care and reasonable duration;the person-centered plan was reviewed and updated in accordance with the organization's policy;when applicable,the transition plan and discharge summary have been completed; services were documented in accordance with the organization's policy;and when billing for services occurs,clinical documentation is consistent with billing records. I.5.a. through I.5.c. The organization should demonstrate that information collected from its review process is used to improve the quality of its services,used to identify personnel training needs,and reported to applicable personnel. SECTION 3. OPIOID TREATMENT CORE PROGRAM STANDARDS Principle Statement The standards and intent statements in this section address the unique characteristics of each type of core program area. Opioid treatment programs provide rehabilitation and medical support for persons addicted to opioid drugs.The duration of treatment should be based on the needs of the persons served and should take into consideration the benefits of medication. Medications used to achieve treatment goals include methadone or other opioid agonist treatment medications approved by the Food and Drug Administration for use in the treatment of opioid addiction. Some other nonopioid agonist drugs have been determined to be efficacious and generally acceptable in current practice. Services are directed at reducing or eliminating the use of illicit drugs, criminal activity,and/or the spread of infectious disease while improving the quality of life and functioning of the persons served. Opioid treatment programs follow rehabilitation stages of sufficient duration to meet the needs of the persons served. Car I INTERNATIONAL Page 18 enhancing PEOPLE'S LIVES F. Outpatient Treatment Principle Statement Outpatient treatment programs provide services that include,but are not limited to,individual, group,and family counseling and education on recovery and wellness. These programs offer comprehensive,coordinated,and defined services that may vary in level of intensity. Outpatient programs may address a variety of needs,including,but not limited to,situational stressors, family relations,interpersonal relationships,mental health issues,life span issues,psychiatric illnesses, addictions (such as alcohol or other drugs,gambling,and internet),eating or sexual disorders,and the needs of victims of abuse,domestic violence, or other trauma. Recommendations There are no recommendations in this area. car f INTERNATIONAL Page 19 enhancing PEOPLE'S LIVES