Observations
During a supervisory review of your licensing packet, the reviewer determined that the Staffing Requirements Facility Summary Report form completed by the facility on October 20, 2010 was incomplete.
Findings:
The Staffing Requirements Facility Summary Report that was presented to the Licensing Specialist was incomplete.
Page 1 of the Staffing Requirements Facility Summary Report that was completed by the facility on October 20, 2010 indicated that employee # 2, the clinical coordinator started the project 2/1/2007 and started her current position on 11/15/1999.
Page 2 of the Staffing Requirements Facility Summary Report in reference to employee # 1 was incomplete. The information provided for employee # 1 did not include the annual training requirements and failed to list the date, subject area, provider, and number of hours completed.
Page 4 of the Staffing Requirements Facility Summary Report failed to include the provider of the HIV/AIDS and TB/STD training for employee # 3 & 4. In addition, the reference to annual training requirements for employee # 3 & 4 was incomplete and failed to list the number of hours completed by the facility and an outside trainer.
Page 5 of the Staffing Requirements Facility Summary Report failed to clarify the number of hours dedicated to partial hospitalization.
Page 6 of the Staffing Requirements Facility Summary Report failed to clarify the number of hours dedicated to outpatient caseloads.
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Plan of Correction
Employee # 2 began with the Changes program on 2/1/2007, however has been the Supervisor of Clinical Treatment Programs with the IU since 11/15/99.
An amended page 2 will be submitted by April 1 to accurately reflect the information.
An amended page 4 will be submitted by April 1 to accurately reflect the information.
Corrected pages 5 and 6 were submitted to on February 18 2010
Facility Director is responsible for ensuring the corrective action is implemented.
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