Observations
Based on a review of client records, the facility failed to document an initial individual training plan for a newly hired employee within 30 days from the employee's date of hire in five of eight personnel records reviewed. Also, the facility failed to document an individual training plan that includes potential resources for training which meet the requirements for the employee's position and which relate to the employee's skill level and interest in seven of thirteen personnel records reviewed.
The findings include:
From April 23, 2013 to April 24, 2013, thirteen personnel records requiring documentation of an individual training plan were reviewed. The facility did not document an initial individual training plan for a newly hired employee within 30 days from the employee's date of hire in five of eight records reviewed, specifically, personnel records # 5, 6, 7, 9, and 11. Also, the facility did not document an individual training plan that included potential resources for employees in seven of thirteen records reviewed, specifically, personnel records # 1, 2, 3, 4, 7, 12, and 13.
Employee # 1 is the project director and was hired for his current position August 1, 2005. An individual training plan was completed on November 27, 2012; however, the individual training plan did not include potential resources for employee # 1.
Employee # 2 is the facility director and was hired for her current position September 8, 2008. An individual training plan was completed on December 19, 2012; however, the individual training plan did not include potential resources for employee # 2.
Employee # 3 is one of the clinical supervisors and was hired on July 26, 2012. The initial individual training plan was completed August 2, 2012 and the annual individual training plan was completed December 20, 2012. However, the annual individual training plan did not include potential resources for employee # 3.
Employee # 4 is a counselor and was hired on October 19, 2010. An individual training plan was completed on December 20, 2012; however, the individual training plan did not include potential resources for employee # 4.
Employee # 5 is a counselor and was hired on January 4, 2013. An initial individual training plan was due February 3, 2013. The initial individual training plan was completed but did not include a date of completion.
Employee # 6 is a counselor and was hired on March 1, 2013. An initial individual training plan was due March 31, 2013. The initial individual training plan was completed but did not include a date of completion.
Employee # 7 is counselor and was hired on July 9, 2012. An initial individual training plan was due March 31, 2013. The initial individual training plan was completed but did not include a date of completion. Also, the annual individual training plan was completed on December 19, 2012; however, the individual training plan did not include potential resources for employee # 7.
Employee # 9 is a counselor and was hired on February 13, 2013. An initial individual training plan was due March 11, 2013. The initial individual training plan was completed but did not include a date of completion.
Employee # 11 is a counselor and was hired on January 24, 2013. An initial individual training plan was due February 23, 2013. The initial individual training plan was completed but did not include a date of completion.
Employee # 12 is a counselor and was hired for her current position on May 8, 2011. An individual training plan was completed on December 18, 2012; however, the individual training plan did not include potential resources for employee # 12.
Employee # 13 is a counselor and was hired June 3, 2009. An individual training plan was completed on December 20, 2012; however, the individual training plan did not include potential resources for employee # 13.
The findings were confirmed during an interview with the human resource director on April 24, 2013 at approximately 8:30 A.M.
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Plan of Correction
The individual training plans for employee number 5, 6, 7, 9, and 11 will be amended to include the date of completion effective 5/20/13. Human Resources will insure that going forward that all initial individual training plans for newly hired employees are completed and dated with 30 days of hire. Human Resources Director updated form and added signature and date for employees as well as supervisor to sign off effective 5/20/13. Human Resources Director will do monthly audits to insure compliance.
The individual training plans for employee number 1, 2, 3, 4, 7, 12, & 13 has been amended to include the date of completion effective 5/20/13. Human Resources Director has revised individual training plan to include potential resources for training which meet the requirement for the employee's position as well as to the employee's skill level and interest effective 5/20/13. Human Resources Director will do audits to insure compliance.
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Observations
Based on a review of client records, the facility failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project in three of three client records reviewed.
The findings include:
On April 24, 2013, three client records requiring documentation of the facility notifying the client in writing of a decision to involuntarily terminate the client's treatment at the project were reviewed. The facility did not notify the client in writing of a decision to involuntarily terminate the client's treatment at the project in three of three records reviewed, specifically, client records # 8, 9, and 10
Client # 8 was admitted September 30, 2012 and was involuntarily discharged on October 26, 2012. However, client record # 8 did not include documentation of the facility notifying the client in writing of a decision to involuntarily terminate client # 8's treatment at the project as of April 24, 2013.
Client # 9 was admitted October 9, 2012 and was involuntarily discharged on October 26, 2012. However, client record # 9 did not include documentation of the facility notifying the client in writing of a decision to involuntarily terminate client # 9's treatment at the project as of April 24, 2013.
Client # 10 was admitted October 20, 2012 and was involuntarily discharged on October 26, 2012. However, client record # 9 did not include documentation of the facility notifying the client in writing of a decision to involuntarily terminate client # 10's treatment at the project as of April 24, 2013.
The findings were confirmed during an interview with the facility director on April 24, 2013 at approximately 3:30 P.M.
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Plan of Correction
A multidisciplinary team meets with all clients to review reasons for involuntary discharge. The team has developed a letter that informs the client of the specific reasons for involuntary termination and how the decision to involuntarily terminate was reached. Letter is being used as of May 15, 2013. Compliance will be monitored by Clinical Director or Medical Director at the time any involuntary discharge takes place. The facility will mail letters to clients #8, 9 and 10 on May 21, 2013 notifying them that the facility had decided to involuntarily terminate their treatment. |