Observations
Based on a review of personnel records and the facility policy and procedure manual, the facility failed to ensure they maintained a mechanism to collect feedback on completed training, per their policy, in nine of nine applicable personnel records reviewed.The facility policy and procedure manual stated " Each staff member attending a training workshop or seminar, completing coursework, attending an in-service, viewing training videos, or reviewing written materials shall complete a Staff Training Report. Reports should be completed within one week of the training and submitted to the Program/Clinical Supervisor. "At the time of the inspection, there was no documentation of training feedback forms for external trainings completed in each applicable personnel record reviewed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gaudenzia will collect feedback on all completed trainings. This will be done utilizing our training management system. For training modules which are delivered via the Training Management Vendor Software this feedback will be entered by the employee at the conclusion of the training. For training modules which are delivered via any external sources, the feedback will be entered by the employee at the time that the certificate is uploaded to the training management system. The employee's direct supervisor will review the training transcript at least quarterly to ensure that all completed training and feedback is reflected. The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
Person(s) Responsible
· Clinicians · Clinical Supervisor · Program Director · Division Director · Regional Clinical Director · Director of Audits & Monitoring.
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