Observations
Based on a review of staff records, the facility failed to provide documentation of at least twelve clock hours of annual training required for the project and facility director for the training year July 2024-June 2025 in one of one records.
Staff #1 was hired as the project and facility director on March 1, 1991 and was still in this position at the time of the inspection. During the review of the staff record, only included documentation of eleven training hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Business Manager confirms that Staff # 1 missed the number of required training hours by 1 hour. The requirement of 12 training hours annually has been communicated with Staff #1, and Staff #1 will ensure they have the required training hours in the future. Additionally, all other clinical staff has been reminded of the required annual training hours and they will ensure they have the required training hours.
This will be monitored and supervised by the Business Manager, Admissions Director and the Project Director.
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