Observations
Based on the review of staff records and an interview with the facility director, the facility did not have a mechanism in place to collect feedback for completed training.
The findings include:
Three out of the three staff records reviewed that required feedback for completed training, did not have documentation of feedback for the completed training.
Employee #1 was hired on 11/02/2009, as a counselor. During the onsite inspection conducted on 11/05/2015, the facility had no documentation of feedback from Employee #1 for the training completed in the 07/01/2014, through 06/30/2015, training year.
Employee #2 was hired on 06/23/2008, as a counselor. During the onsite inspection conducted on 11/05/2015, the facility had no documentation of feedback from Employee #2 for the training completed in the 07/01/2014, through 06/30/2015, training year.
Employee #3 was hired on 12/13/2011, as a counselor. During the onsite inspection conducted on 11/05/2015, the facility had no documentation of feedback from Employee #3 for the training completed in the 07/01/2014, through 06/30/2015, training year.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A brief feedback form has been developed and added to the electronic system. The process of completing the form was initiated on 11/20/2015 when several outpatient therapists attended training. Once completed, the forms are turned into Human Resources for filing in the personnel chart.
It is the responsibility of the clinical supervisor, in conjunction with the HR director, to monitor and assure that that the forms are completed and submitted. The official start date is 11/20/2015.
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