Observations
Based on a review of facility records and staff interview, the facility failed to ensure each counselor completed at least 25 clock hours of training annually in one of one applicable record.
Staff #4 was hired to the position of counselor on June 5, 2023 and was in this position at the time of review. During the training year spanning from January 1, 2024 through December 31, 2024, Staff #4 only completed 21 training hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective August 1, 2025, the facility has implemented a structured in-house training program to ensure all counselors meet or exceed the annual 25-hour training requirement. One hour of training will be provided monthly, facilitated by the Clinical Director, covering approved topics under 704.11(f)(2). This reduces the burden on counselors to independently obtain all hours, as they will only need to secure 13 additional training hours annually from outside sources. The Clinical Supervisor has reviewed all current counselor training hour logs to verify compliance to date and will meet individually with any counselor at risk of falling short to schedule additional training before the end of the training year.
This procedure will remain in place to ensure that all current and future counselors meet the training hour requirement. In-house training content will align with approved subject areas listed in 704.11(f)(2). The Clinical Supervisor will track cumulative training hours for each counselor on a quarterly basis using a standardized tracking form.
The Clinical Supervisor will review training hour logs quarterly, documenting the review on the Training Compliance Log. Any counselor projected to be under the required hours will be scheduled for additional training within the same quarter. The Clinical Director will maintain documentation of all in-house training sessions, including attendance records, to verify completion. |