Observations
Based on a review of administrative information, the facility failed to collect feedback on completed trainings in three of five personnel records reviewed.
Facility policy and procedures state that feedback forms are to be completed after each training.
The training year beginning July 1, 2023, through June 30, 2024 was reviewed and feedback was not collected for each training.
Staff #1 was hired on May 24, 2021.
Staff #2 was hired on July 1, 2023.
Staff #5 was hired on May 4, 2019.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Human Resources Department will issue the internal staff feedback form each time a staff member attends a training. The Human Resources Department will not consider the training completed for training requirements unless both the feedback form and the CEU certificate is submitted. Human Resources Department will monitor staffing files monthly to ensure feedback forms are completed. |
Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in four of five records.
Client #3 was admitted on December 6, 2023, and discharged on March 11, 2024. A treatment plan was completed on December 18, 2023, and an update was due no later than February 18, 2024; however, there were no updates in client #3 ' s record.
Client #5 was admitted on November 1, 2023, and was still active at the time of the inspection. A treatment plan was completed on November 20, 2023, and an update was due no later than January 20, 2024; however, it was completed on February 8, 2024.
Client #6 was admitted on January 18, 2024, and was still active at the time of the inspection. A treatment plan update was completed on April 2, 2024, and the next update was due no later than June 2, 2024; however, there were no updates in client #6 ' s record.
Client #7 was admitted on December 28, 2023, and was still active at the time of the inspection. A treatment plan was completed on January 10, 2024, and an update was due no later than March 10, 2024; however, it was completed on March 13, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Clinical Director will hold an Outpatient Staff meeting by August 1, 2024 to review with staff that an update to treatment plan will be done without client signature every 30 days. Future internal chart audits will ensure that all updates are done within 30 days with our without client signature at that point. Clinical Supervisor and/or Program Lead will conduct monthly chart audits to ensure treatment plans are done within time frames. |