Observations
Based on a review of administrative documentation and the facility's policy and procedure manual, the facility failed to document an annual evaluation of the overall training plan within the policy time frame.
The findings include:
The policy and procedure manual and administrative documentation was reviewed on September 24, 2012. The facility's policy identified the training year as January to December. The annual evaluation of the overall training plan due date is identified as year end. The administrative documentation of the annual evaluation for 2011 was dated September 21, 2012.
The findings were reviewed with the Project Director, Facility Director and clinical staff and the findings were not disputed.
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Plan of Correction
The Director of Addiction Services will evaluate the progress made by staff in pursuit of their training hours. This evaluation will be completed at the end of the calendar year 12/31.
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