INITIAL COMMENTS
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This is a report of the on-site licensure renewal inspection conducted on July 23 through 24, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 23, 2007.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
The facility failed to document an assessment of staff training needs in two of five employee records reviewed, # 4 and 5.
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Plan of Correction
Our project will be in full compliance with this standard by September 1, 2007. Our facility uses a questionnaire, which is completed by each employee every year. The proper completion of this questionnaire, as well as the standard will be reviewed with each of the three employees mentioned. This will be done by the Clinical Supervisor in individual supervision. The questionnaire will then be fully and properly completed for each of these employees. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to ensure feedback forms were completed for training attended in two of five employee records reviewed, #2 and 5.
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Plan of Correction
Our project will be in full compliance with this standard by September 1, 2007. Our facility uses a feedback form, which is to be completed by each employee for every training which is attended. The proper completion of this form, as well as the standard will be reviewed with each of the two employees mentioned. This will be done by the Clinical Supervisor in individual supervision. The feedback forms will then be fully and properly completed for each training that these employees attended. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to document individual training plans in two of five employee records reviewed, #4 and 5.
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Plan of Correction
Our project will be in full compliance with this standard by September 1, 2007. Our facility uses a questionnaire, which is to be completed by each employee every year. The proper completion of this questionnaire, as well as the standard will be reviewed with each of the two employees mentioned. This will be done by the Clinical Supervisor in individual supervision. The questionnaires will then be fully and properly completed by each of these employees in collaboration with the Clinical Supervisor. Additionally, we have been working with our Licensing Specialist to modify and improve our questionnaire to more fully comply with this standard. |