Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee #6 was hired as a counselor on January 4, 2022. The TB/STD training was due to be completed no later than January 4, 2023; however, the training was not completed at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #6 completed the TB/STD training on 11/8/23 and all other staff are currently up to date with all training needs.
Individualized training plans will be updated on 12/1/23 with Facility Director, and all rostered staff. These plans will reflect the training needs of each staff member rostered under our DDAP license.
A tracking system will be created to manage all new hires and all training assignments ongoing with staff. If there are issues with staff getting into trainings within the DDAP TMS system, this agency will utilize its internal training system, Relias, to assign and complete trainings until a DDAP training becomes available. As new trainings become available or required by DDAP regulations, these will be added to all staff's trainings plans and scheduled accordingly.
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Observations
Based on a review of client records, the project failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of seven client records reviewed.
Client #1 was admitted on January 30, 2023 and was active at the time of inspection. A treatment and rehabilitation plan update was completed on March 3, 2023 and the next update was due no later than May 3, 2023; however, the update was not completed until May 30, 2023. Additionally, a treatment and rehabilitation plan update was completed on May 30, 2023 and the next update was due no later than July 30, 2023; however, the update was not completed until August 15, 2023.
Client #2 was admitted on March 15, 2023 and was active at the time of inspection. A treatment and rehabilitation plan update was completed on April 24, 2023 and the next update was due no later than June 24, 2023; however, the update was not completed until June 30, 2023. Additionally, a treatment and rehabilitation plan update was completed on June 30, 2023 and the next update was due no later than August 30, 2023; however, the update was not completed until October 12, 2023.
Client #4 was admitted on October 31, 2022 and was discharged on February 3, 2023. The comprehensive treatment and rehabilitation plan was completed on October 31, 2022 and the first update was due no later than December 31, 2022; however, the update was not completed prior to client ' s discharge.
Client #5 was admitted on February 8, 2023 and was discharged on July 20, 2023. A treatment and rehabilitation plan update was completed on March 31, 2023 and the next update was due no later than May 31, 2023; however, the update was not completed until June 12, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff meeting was held on 11/13/23 to review this citation, inform all staff of the 709.92 policy related to treatment planning, and discuss ways to improve our practice moving forward.
Our Clinical Operations Manager has created a tracking system for treatment plans and will utilize our e-clinical system to schedule treatment plan updates moving forward.
All members of the clinical team were trained further on this during our group supervision on 11/20/23 and it will be reviewed ongoing during individual supervision and when completing case consults. Clinical team was made aware of the need for plans to be comprehensive at the start of treatment and to be updated even without the individual present moving forward, even during the discharge period.
A quarterly audit related specifically to this policy will be instituted and implemented by internal audit team to ensure this will not continue as a repeat violation.
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