Observations
Based on a review of applicable personnel records, the facility failed to provide written individual training plans that were developed with input from the employee and the supervisor in accordance with facility's policy. The facility's policy states that initial training plans will be completed with input from the employee and the supervisor within ninety days of hire. The policy also states that annual training plans will be completed with input from the employee and the supervisor within sixty days of the new training year.
Staff #3 was hired as a counselor on July 21, 2025 and was still in this position at the time of the inspection. The initial training plan was due no later than October 21, 2025; however, this was not completed until March 10, 2026.
Staff #4 became a counselor on July 15, 2016 and was still in this position at the time of the inspection. The annual training plan for the July 2025 through June 2026 training year was due no later than September 30, 2025; however, this was not completed until March 5, 2026.
Staff #5 was hired as a counselor on October 4, 2004 and was still in this position at the time of the inspection. The annual training plan for the July 2025 through June 2026 training year was due no later than September 30, 2025; however, this was not completed until March 10, 2026.
Staff #6 was promoted to a counselor on June 2, 2024 and was still in this position at the time of the inspection. The annual training plan for the July 2025 through June 2026 training year was due no later than September 30, 2025; however, the documented training plan did not have the date it was completed. Additionally, the training plan did not include documentation of input from the employee or the supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges the findings related to untimely and incomplete employee training plans. To prevent recurrence, the facility will implement the following corrective actions:
- A centralized tracking system will be maintained to monitor due dates for all initial and annual training plans.
- Supervisors will receive re-education on the policy requirements, including required timelines, employee/supervisor participation, and documentation standards.
- Program leadership will conduct quarterly audits of training files to ensure compliance with training plan requirements.
The facility expects full ongoing compliance with this requirement moving forward.
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