Observations
Based on one of three applicable employee personnel records reviewed, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year January-December 2021.
Employee # 3 was hired as a counselor on December 27, 2019 and was still in this position at the time of the inspection. After a review of employee #3 ' s personnel record, there was only 18 training hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction: Facility # 367095
Community Care & Addiction Recovery Services (CCARS) has created the following POC in response to a deficiency found during an on-site licensing renewal inspection conducted on 09/13/2-22. It was found that employee #3's personnel record, that was reviewed, revealed a deficiency of the required 25 training hours annually for that position, as they only completed 18 hours.
The Project Director spoke with #3 employee regarding this deficiency and the steps that needs to happen to avoid this deficiency from re-occurring this new fiscal year (2022-2023). Employee #3 has already signed up for DDAP trainings to ensure completion of ALL 25 hours of training for this new fiscal year. All CCARS staff were retrained by the Project Director individually, verbally and via email regarding the completion annually of the required number of training hours by DDAP for their specific position at CCARS, to ensure they understand the importance of complying with this requirement. This was addressed immediately upon completion of the annual licensing inspection.
To ensure this deficiency does not reoccur, the Project Director will periodically inspect all personnel files for compliance of DDAP training hour regulations for each position held at CCARS. Project Director will ensure each employee is on track to complete their required # of training hours each fiscal year.
Facility to be in full compliance for fiscal year 2022-2023 and going forward.
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