Observations
Based on a review of personnel and training records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of two personnel training records reviewed.
The findings include:
Six personnel records were reviewed on October 1, 2010. Two personnel training records were counselors that were required to include documentation of the completion of 25 clock hours of annual training for the January to December 2009 training year. The facility failed to document 25 clock hours of annual training in personnel records # 4 and #6.
Employee # 4 was hired on August 6, 2007. The facility training year is from January through December. The training year for January 2009 to December 2009 was reviewed. Employee # 4 completed 22 clock hours of annual training in 2009.
Employee # 6 was hired on January 28, 2004. The facility training year is from January through December. The training year for January 2009 to December 2009 was reviewed. Employee # 6 completed 0 clock hours of annual training in 2009.
The Human Resource Director confirmed on October 1, 2010 that the counselors did not have the 25 clock hours of training for the 2009 training year. The Program Director confirmed on October 12, 2010 that the counselors did not have the 25 clock hours of training for the 2009 training year.
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Plan of Correction
The Program Director is responsible for ensuring all staff have met the 25 clock hours of required annual trainings. This will be completed by Dec 30, 2010. Pyramid will continue to monitor this process by doing quarterly audits to ensure staff are trained on an annual basis. |
Observations
Based on a review of the client records, the facility failed to document progress notes which contained the assessment in four of the seven required records. The assessment should include the counselor's analysis of and conclusions regarding the client's current situation or status.
The findings include:
Eleven client records were reviewed on October 12, 2010. Seven of the eleven client records were reviewed as part of the outpatient activity. Seven client records were required to include documentation of the progress notes that include an assessment. Four of the seven records, records # 5, 7, 8, and 11, did not include this documentation.
Client #5 was admitted on 7-12-10. The group progress notes that did not include an assessment were dated 7-12-10, 7-13-10, 7-15-10, 7-19-10, 7-20-10, 7-22-10, 7-26-10, 7-27-10, 7-29-10, 8-2-10, 8-3-10, 8-5-10, 8-9-10, 8-10-10, 8-12-10, 8-16-10, 8-17-10, 8-19-10, 8-23-10, 8-24-10, 8-26-10, 9-7-10, 9-8-10, 9-13-10, 9-15-10, 9-22-10, 9-29-10, and 10-6-10.
Client #7 was admitted on 9-1-10. The group progress notes that did not include an assessment were dated 9-1-10, 9-8-10, 9-15-10, 9-22-10, 9-29-10, and 10-6-10.
Client #8 was admitted on 7-28-10, and was discharged on 9-15-10. The group progress notes that did not include an assessment were dated 7-28-10, 8-4-10, 8-11-10, 8-18-10, and 8-25-10.
Client #11 was admitted on 8-18-10 and discharged 9-29-10. The group progress notes that did not include an assessment were dated 8-18-10, 8-25-10, 9-1-10, and 9-8-10.
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Plan of Correction
The Program Director is responsible for ensuring all staff are trained on how to document proper notes for individual notes and group notes. All staff will be re-trained on how to report Data, Assessment & Plan, and how it correlates to the client's treatment plan. This training will be completed by the Program Director. This will be completed by Dec 30, 2010. Pyramid will continue to monitor this process by doing internal audits and clinical supervision to monitor this improvement. |