Observations
Based on a review of administrative information, the facility failed to ensure counselors received the minimum of at least 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment in one of eleven applicable records.
Staff #7 was hired as counselor on October 14, 2024, and still employed at the time of inspection. Staff #7 was due to have the communicable disease trainings no later than October 14, 2025; however, it was completed May 27, 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By 7/21/26, Program Director will educate all counselors and counselor assistants of the 704.11 Mandatory Communicable Disease Training requirement to be completed within the first year of employment. All other staff will complete the training within the first 2 years of employment. Staff roster will be kept on file for training.
Program administrator will use a spreadsheet to track all due dates of mandatory education of counselors, counselor assistants and other staff, effective 7/21/26. Program Supervisors will review the tracking spreadsheet monthly and inform staff of their due date to complete mandatory training, effective 7/21/26.
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Observations
Based on a review of administrative information, the facility failed to ensure staff were instructed in the use of fire extinguishers upon employment in one of eleven applicable records.
Staff #19 was hired as a counselor on December 29, 2025, and still employed at the time of inspection. The training was completed May 26, 2026.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By 7/15/26, Program Director will educate all supervisors of the 705.28 Fire Safety regulations to ensure that all new or transferred staff are instructed in using the fire extinguisher upon hire. Staff roster will be kept on file.
Effective 7/15/26, Program administrator will use a spreadsheet to track new hire or transferred staff hire dates. Program Supervisor will be responsible for training all new staff or transferring staff on the use of the fire extinguisher upon the first day of employment.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in six of seven records.
Client #1 was admitted on August 19, 2025, and discharged on March 4, 2026. A treatment plan update was completed on November 3, 2025, and the next update was due no later than January 3, 2026; however, it was completed on January 5, 2026.
Client #2 was admitted on October 13, 2025, and discharged on May 6, 2026. A treatment plan was completed on November 6, 2025, and an update was due no later than January 6, 2026; however, it was completed on February 2, 2026.
Client #3 was admitted on November 25, 2025, and discharged on May 11, 2026. A treatment plan update was completed on February 16, 2026, and the next update was due no later than April 17, 2026; however, it was completed on April 20, 2026.
Client #5 was admitted on January 12, 2026, and was still active at the time of the inspection A treatment plan was completed on January 12, 2026, and an update was due no later than March 12, 2026; however, it was completed on May 5, 2026.
Client #6 was admitted on January 15, 2026, and was still active at the time of the inspection A treatment plan update was completed on March 10, 2026, and the next update was due no later than May 10, 2026; however, it was completed on May 21, 2026.
Client #7 was admitted on January 6, 2026, and was still active at the time of the inspection A treatment plan update was completed on February 11, 2026, and the next update was due no later than April 12, 2026; however, it was completed on April 13, 2026.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 17, 2025, licensing inspection.
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Plan of Correction
By 7/21/26, Program Director will educate all staff on the repeat citation of treatment plans being reviewed and updated at least every 60 days, which includes the weekend days. If a treatment plan review/update falls on a weekend, the staff will update the treatment plan review prior to the weekend and/or staff's vacation. Staff roster of training will be kept on file.
The caseload tracker of treatment plan reviews / updates is reviewed weekly and discussed in supervision. Effective, 7/15/26, Program Supervisor will be responsible for reviewing the weekly caseload tracker to ensure all treatment plans are completed within the 60-day time frame.
Effective, 7/15/26, program supervisors will be responsible for running a treatment plan report weekly and staff are notified of any lapsed plans and plans that are coming due within the next 14 days to ensure treatment plan reviews are updated at least every 60 days. Upon notification of a missing treatment plan review or update, the supervisor will provide additional support to ensure the treatment plan review/update is completed within 24 hours.
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