Observations
Based on a review of personnel records, the facility failed to document individual training plans in accordance with facility policy in one of two records.
The findings include:
On May 11, 2011 employee # 1 personnel record was reviewed.
The project failed to develop an individual training plan annually in accordance with policy.
The facilities policy titled " Plan for Assessment of Staff Training Needs" states:
In January of each year, the Program Director, in conjunction with the Supervisor, will conduct needs assessments, via individual training plan forms for all employees, to determine what topics and areas of training should be provided during the coming year.
Employee # 1 has been the project director since 1988.
Per policy, training plans will be conducted in January of each year.
The facility failed to document an individual training plan in January for employee # 1.
An individual training plan was documented on 5/31/11 for employee # 1.
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Plan of Correction
The projects governing body will ensure that the Project Director has a documented training plan on file in January of each year by the 31st. The governing body will complete the Project Director's training plan during the last board meeting of the calendar year to ensure that this deficiency does not reoccur during future inspections. Moving forward the governing body will ensure that the Project Director's training plan is complete and on file by January 31st of each year. The Project Director's training file shall be complete and ready for review during the projects annual administrative review. Furthermore, a recurring reminder will be created in Microsoft Outlook for the Program Director and Administrative Assistant scheduled for January 1st to remind them that All Training Plans are to be completed by January 31st of each year. |