Observations
Personnel records were reviewed for the facility's licensing renewal inspection, conducted on May 9-10, 2017. The facility's last complete training year of June 1, 2015 - May 31, 2016 was reviewed. Based on a supervisory review of personnel records, the facility failed to document the completion of at least 25 annual training hours for all applicable counselors, specifically employee records # 10 and 11. Employee # 10 was hired by the facility on 5/19/03 and assumed the Counselor position on 6/11/06. Documentation in the employee's record indicated that the employee completed 21.5 hours of annual training for the reviewed training year. Employee # 11 was hired by the facility on 12/2/13 as a Counselor. Documention in the employee's record indicated that the employee completed 21.5 hours of annual training for the reviewed training year. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Staff Development will re-educate clinical staff of the training hours requirement via memo by July 1. Horsham Clinic will purchase and create individual accounts for Clinical staff with CEUs online by 7/31/2017. The Director of Staff Development will track and manage the CEU account to ensure that all Clinical Staff fulfill their training hours. |