Observations
Based on a review of the facility's policy and procedure manual and administrative materials, the facility failed to document an annual evaluation of the overall training plan.
The findings include:
The facility's policy and procedure manual and administrative materials were reviewed on July 6, 2012. The facility policy titled "Staff Development Program" states the following:
"At the end of each training year, an annual evaluation will be made to determine what extent the plan addressed the identified needs as laid out in the initial assessment. This shall be completed by December 31 of each year."
An annual evaluation of the overall training plan was due to be completed no later than December 31, 2011 for the January 1 - December 31, 2011 training year. As of July 6, 2012, the facility failed to document an annual evaluation of the overall training plan for the January 1 - December 31, 2011 training year.
The project/facility director was interviewed on July 6, 2012 at approximately 11:45 AM and confirmed the findings.
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Plan of Correction
Jade Wellness Center's Practice/Facility Director had corrected this deficiency in the 12/15/2011 plan and inserted it into the Policy and Procedure Manual. It is the responsibility of the new Director, Lucy M. Garrighan and the Vice President of Operations, Abbie Scanio, to keep up with this deficiency and ensure it does not re-occur. |