Observations
Based on a review of staff records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually in one of three records.
Staff #4 was hired to the position of counselor on December 8, 2021 and is still in this position. At the time of review, staff #4 had documentation for only 12 clock hours of training during the facilities training year spanning January 1, 2022 through December 31, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff Training Hours
Explanation: The counselor in question states that she completed training the additional 13 hours needed for training compliance but could not access the certificates from the online training provider. Regardless, she did not produce certificates and the Clinical Supervisor trusted that they would be produced. As a result, a deficiency was created.
Proposed Timeframe for Achieving Compliance: Compliance has already been achieved. Staff #4 has already acquired sufficient number of training hours to comply with DDAP annual training requirements.
Methodology for Achieving and Maintaining Compliance: Positive Pathways will maintain compliance by requiring all training certificates are produced and turned into the Clinical Supervisor within one week of completion and training hours will not be added towards the total needed if not turned in within a week. The Clinical Supervisor will address and update monthly in staff supervision and will be documented in supervision notes. Clinical Supervisor will also report to the Program Director on a monthly basis during the staff meeting which will be reflected in staff meeting notes. |