Observations
Based on the review of the Staffing Requirements Facility Summary Report (SRFSR) completed by the project, the facility failed to document individual training plan for each employee upon employment or annually in accordance with the facility's policy.
The findings include:
According to the SRFSR completed by the project ' s staff, the facility ' s training year runs from January 1st to December 31st.
The facility ' s policy regarding staff development states, Training plans are due by January 15th of the current training year.
The SRFSR was reviewed on April 2, 2012 through April 4, 2012. Of the two hundred twenty-nine personnel identified on the SRFSR, the facility documented that 66 employees either did not have a training plan upon employment, did not have an annual training plan by January 15th, or did not have documentation of a training plan at all.
Employee #6 ' s training plan was not documented until 4/5/12.
Employee #7 was hired on 1/9/12, the training plan is to be documented upon hire. The training plan for employee #7 had not been completed until 4/5/12.
Employee #9 was hired on 6/23/11, the training plan is to be documented upon hire. The training plan for employee #9 had not been completed until 8/22/11.
Employee #11 was hired on 1/18/12, the training plan is to be documented upon hire. The training plan for employee #11 had not been completed as of the date of inspection.
Employee #13 was hired 9/9/11, the training plan is to be documented upon hire. The training plan for employee #13 had not been completed until 12/7/11.
Employee #16 was hired on 2/21/12, the training plan is to be documented upon hire. The training plan for employee #16 had not been completed as of the date of inspection.
Employee #17 was hired on 1/9/12, the training plan is to be documented upon hire. The training plan for employee #17 had not been completed as of the date of inspection.
Employee #25 ' s training plan was not documented until 1/19/12.
Employee #35 was hired on 3/2/12, the training plan is to be documented upon hire. The training plan for employee #35 had not been completed as of the date of inspection.
Employee #40 was hired on 1/9/12, the training plan is to be documented upon hire. The training plan for employee #40 had not been completed as of the date of inspection.
Employee #43 was hired on 2/20/12, the training plan is to be documented upon hire. The training plan for employee #43 had not been completed as of the date of inspection.
Employee #54 was hired on 1/18/12, the training plan is to be documented upon hire. The training plan for employee #54 had not been completed as of the date of inspection.
Employee #55 was hired on 2/9/12, the training plan is to be documented upon hire. The training plan for employee #55 had not been completed as of the date of inspection.
Employee #59 was hired on 1/9/12, the training plan is to be documented upon hire. The training plan for employee #59 had not been completed as of the date of inspection.
Employee #65 was hired on 1/9/12, the training plan is to be documented upon hire. The training plan for employee #65 had not been completed as of the date of inspection.
Employee #66 was hired on 1/9/12, the training plan is to be documented upon hire. The training plan for employee #66 had not been completed as of the date of inspection.
Employee #67 was hired on 1/9/12, the training plan is to be documented upon hire. The training plan for employee #67 had not been completed as of the date of inspection.
Employee #68 was hired on 1/19/12, the training plan is to be documented upon hire. The training plan for employee #68 had not been completed as of the date of inspection.
Employee #72 was hired on 1/20/12, the training plan is to be documented upon hire. The training plan for employee #72 had not been completed as of the date of inspection.
Employee #76 was hired on 1/16/12, the training plan is to be documented upon hire. The training plan for employee #76 had not been completed as of the date of inspection.
The training plan was not documented for employees #15, 18 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, 30, 31, 32, 33, 34, 36, 37, 39, 41, 42, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 56, 57, 58, 60, 61, 62, 63, 64, 69, 70, 71, 73, 74, and 75.
The Quality Assurance staff was informed of the findings during the exit interview.
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Plan of Correction
Plan of Correction:
It is the responsibility of each employee and their immediate supervisor to write and individualized training plan upon hire and annually thereafter to determine the needs for overall training program.
This individualized training plan is due to the QI department annually by the January 15th of each calendar year and upon employment.
The individualized training plans are received into the facility from the QI department. Managers/supervisors distribute the plans to the employees. The managers/supervisors in each department complete the form with their individual employees. The forms will be collected and returned to the QI department by January 15th of each calendar year.
The manager/supervisor will forward an individualized training plan to the QI department after hiring a new employee.
Each manager/supervisor will be held accountable to the facility's Assistant Administrator for timely completion and submission of annual training plans.
The QI department will monitor and distribute a bi-weekly lsiting of new hires needign individualized training plans.
The administrative assistant will monitor/track and remind managers to complete new hire training paln with all new employees.
The adminsitrative asssistant will forward all completed training plans to the QI department within 30 days of hire.
This process will provide a double check of timely submission of individualized traingin plans.
Responsible staff: Managers; adminitrative assistant and Asssitant Administrator.
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