Observations
Based on a review of personnel files and the facility ' s Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed the mandatory 6 hours of HIV/AIDS training within the regulatory time frame in one of five applicable personnel records reviewed.
Employee #4 was hired as a counselor on April 5, 2021. The HIV/AIDS training was due to be completed no later than April 5, 2022; however, the training was not completed at the time of inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #4 has completed the required HIV/AIDS training as of 5/17/2022. Certificate has been added to employee #4's file.
During the 6/3/2022 staff meeting/supervision session Executive Director informed all staff members that they must submit registered confirmations for all of their mandatory yearly trainings to Administrative Coordinator a minimum of 60 days prior to the deadline to complete these trainings.
Administrative Coordinator will keep a log of all staff trainings and notify Executive Director of any staff that does not submit the requested registration in this time frame.
Executive Director will address the staff member and provide resources and support as needed to ensure they are registered for the training and it is completed before the deadline. |
Observations
Based on a review of client records, the facility failed to document that treatment plans were reviewed and updated at least every 60 days in four of seven client records reviewed.
Client #1 was admitted July 1, 2021 and was active at the time of inspection. A treatment plan update was completed on August 9, 2021 and the next update was due no later than October 9, 2021; however, the update was completed on November 4, 2021. Additionally, the next update was due no later than January 4, 2022; however, the update was completed on January 12, 2022. Finally, the next update was due no later than March 12, 2022; however, the update was completed on April 11, 2022.
Client #3 was admitted October 25, 2021 and was active at the time of inspection. A treatment plan update was completed on February 24, 2022 and the next update was due no later than April 24, 2022; however, the update was completed on May 3, 2022,
Client #5 was admitted September 30, 2021 and was discharged January 31, 2022. A treatment plan update was completed on October 27, 2021 and the next update was due no later than December 27, 2021; however, the update was completed on January 6, 2022.
Client #7 was admitted October 4, 2021 and was discharged April 11, 2022. A treatment plan update was completed on November 3, 2021 and the next update was due no later than January 3, 2022; however, the update was completed on January 13, 2022.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Executive Director will conducted a supervision during staff meeting on 6/3/2022 to review the proper timeframe for tx plan updates. Per the suggestion of DDAP auditor staff will be informed that they are to utilize non-billable notes when clients miss a session and as a result a tx plan update is delayed to reflect why it was completed after the designated due date. Staff willl sign off on supervision and be informed that failure to comply may result in sanctions up to and including termination.
Administrative Coordinator and Executive Director will continue to monitor the tx plan updates to ensure compliance. |