Observations
Based on a review of personnel records on February 15, 2017, the facility failed to ensure that an individual training plan was documented for each employee.
Employee #6 was hired as a counselor on May 23, 2016. An individual training plan for the employee was not documented in the chart at the time of the review.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director/Facility Director will keep a list of all existing employees in a excel spreadsheet in which will be kept in a locked folder in the servers public drive. This file can be accessed by management only. The DATA will include all completed training for the year, all required training and completion dates, and date that the annual training plans are due.
As training is completed the data will be updated in the spreadsheet by the Clinical Director. The Clinical Director will provide the training certificate, evaluation, and request in completion to the Project Director the first supervision per month. The Project Director will then match the information to the information in the spreadsheet for accuracy and will file the training in the employee file.
The Project Director will continue to send out the annual evaluation and training plan to the clinical directors the first day of November. The Clinical Director will provide the documents to the staff and have them complete the evaluation within 10 days during supervision time.
The Clinical Director will review the evaluation with the Project Director to determine what training is essential for that particular employee. The Clinical Director will then meet with the employee the following week in supervision and review and sign the document.
Every Clinical Director will submit the evaluation and plan to the Project Director by the 1st of December. The Project Director will review for accuracy, missing data, and missing signatures. Any missing information will be sent back to the Clinical Director for completion. The Clinical Director will have 7 days to return the information to the Project Director.
The Project Director will then use the excel spreadsheet in the locked file to mark collected and approved for each employee. If the Project Director still is missing information the Project Director will again request the information from the Clinical Director and the Clinical Director will have 48 hours to submit the information.
The Project Director provided training to the Clinical Directors regarding this information on 2/3/17 |