Observations
Based on the review of personnel records, the facility failed to document at least 25 hours of training annually for two counselors.
The findings include:
Nine counselor records were reviewed during the 2010-2011 training year on July 26, 2011 for documentation of 25 clock hours of training. The facility failed to document 25 hours of training during the 2010-2011 training year in record # 25 and #27.
Employee #25 was hired on February 3, 2011 and had documented 14.5 hours of training during the July 26, 2011 inspection.
Employee # 27 was hired on January 15, 2009 as a counselor assistant and promoted to a counselor on on June 10, 2011. Employee #27 had only 13 documented training hours during the July 1, 2010 through June 30, 2011.
This was out of compliance at the time of the follow-up conducted on January 6th, 2012.
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Plan of Correction
1. Current practice has been for individual training plans to be conducted with the annual performance evaluation. Evaluations were postponed in fiscal year 2011 to roll out a new evaluation process as a performance improvement initiative. With this change in process, individual training plans were delayed. Individual training plans for fiscal year 2012 will be developed for all counseling staff by September 29, 2011.
2. A Departmental Compliance Objective (DCO) will be developed for the Human Resources Department to monitor the completion of individual training plans. This will be monitored on a monthly basis starting on September 30, 2011. The Chief Compliance Officer will conduct monthly audits of counseling staff training records starting on October 3, 2011 to ensure training records contain individual training plans .
3. The Human Resources Director will develop a policy for individual training plans by August 29, 2011. This policy will include the requirements and timeframes for completion of individual raining plans for employees. Once a policy is developed, a copy will be distributed to all supervisors at Eagleville for review.
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