Observations
Based on a review of personnel records, the facility failed to have staff persons receive at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the first year of employment, in one of three records reviewed.Employee #3 was hired for the position of counselor on October 16, 2023 and is still current in that position. Employee #3 was due to have tuberculosis and sexually transmitted disease training by October 16, 2024, but it was not documented until August 10, 2025. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Going forward, the facility director will ensure that all mandatory trainings will be completed within the first year of the new staff's position within the program. This will be monitored monthly by the facility director.
In the event that one of the mandatory trainings cannot be accessed in a timely fashion, the facility director will look into seeking a temporary exemption until the training can be accessed.
In the event that the training(s) continue to be difficult to ascertain, the facility director will coordinate with the program director to work on developing a training in-house that will meet the training requirement. |
Observations
Based on a review of outpatient client records, the facility failed to follow their written procedures to complete progress notes within 24 hours of counseling session in three out of seven applicable client records reviewed. Client #2 was admitted to the outpatient program on August 12, 2024 and was discharged March 12, 2025. The record identified individual sessions occurring on December 13, 2024, January 3, 2025, January 31, 2025, February 7, 2025, and February 28, 2025, that were not documented until December 15, 2025, January 5, 2025, February 3, 2025, February 9, 2025, and March 2, 2025, respectively. Client #3 was admitted to the outpatient program on March 4, 2025 and was discharged April 16, 2025. The record identified individual sessions occurring on March 27, 2025, April 3, 2025, and April 10, 2025, that were not documented until March 30, 2025, April 5, 2025, and April 22, 2025, respectively. Client #5 was admitted to the outpatient program on February 5, 2024 and was discharged August 5, 2025. The record identified individual sessions occurring on January 7, 2025, January 14, 2025, March 18, 2025, April 29, 2025, June 10, 2025, and July 28, 2025, that were not documented until January 9, 2025, January 16, 2025, March 20, 2025, May 3, 2025, June 12, 2025, and July 31, 2025, respectively. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 9/16/25, the facility director consulted with the program director and agreed to extend the window in which progress notes are to be completed from 24 to 48 hours in an attempt to give staff a more reasonable amount of time to complete them. The policy has been changed to the following:
"Progress notes are completed by each staff member after any contact with the consumer. Notes for face-to-face visits are dated and written in a DATA-ASSESSMENT-PLAN format and are signed with the full name and degree of the clinician. These notes are to be completed within 48 hours of the service delivered."
In order to ensure that staff are in compliance with the policy change, the facility director will monitor staff notes for compliance for the next month. All staff were made aware of this policy change via email. |