Observations
Based on a review of seven staff training records on September 28, 2021, the facility failed to ensure there was a mechanism to collect feedback on completed training in all seven records reviewed.
No trainings for the past training year had a mechanism to collect feedback regarding documented trainings.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
9/28/2021 Facility Director told Clinical Supervisor to remind all staff to complete the form we have for evaluation of training each time they submit a training certificate to us. On 9/30/2021 Clinical Supervisor reminded all staff at the weekly staff meeting to complete the evaluation of training form for each training they attend. A blank copy of the form was given to each staff. Clinical Supervisor will review certificates of training turned in by staff weekly and obtain completed form from staff. Facility Director will inform Clinical Supervisor in the event a staff does not include this form when staff give certificates to Director. Clinical Supervisor will follow up with all staff if this occurs. Clinical Supervisor will review during weekly staff meetings and inform staff to turn in any missing certificates along with the evaluation form. Clinical Supervisor has created individual development plans to address all areas that we received citations for. Clinical Supervisor will review these plans with staff every 90 days and further disciplinary action will be taken as needed. |
Observations
Based on a review of seven staff records conducted during the inspection on September 28, 2021, the facility failed to ensure that two staff had the mandatory training in communicable diseases within the required time frames.
Staff #5 was hired as a counselor on June 15, 2020. The staff person was required to have 6 hours of HIV/AIDS training by June 15, 2021, but at the time of the inspection, the staff person had no documentation of training in this area.
Staff #6 was hired as a counselor on August 1, 2018. The staff person was required to have 4 hours of TB/STD training by August 1, 2019, but at the time of the inspection, the staff person had no documentation of training in this area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/30/2021 Clinical Supervisor reminded Staff # 5 and Staff #6 to sign up for the required HIV/AIDS and TB/STD trainings as soon as available. Facility is adding the Relias Training System to ensure that all staff have access to required trainings when the trainings are not available elsewhere. Clinical Supervisor will monitor all staff's trainings and ensure they are completed within the required time frame. Facility Director will meet with Clinical Supervisor for supervision and review progress on staff training. Clinical Supervisor has created individual development plans to address all areas that we received citations for. Clinical Supervisor will review these plans with staff every 90 days and further disciplinary action will be taken as needed. |
Observations
Based on a review of seven client records on September 28, 2021, the facility failed to document treatment plan updates within the regulatory timeframe in six out of seven client records reviewed.
Client #1 was admitted on October 26, 2020 and was still active at the time of the inspection. A treatment plan update was completed on November 9, 2020 and the next update was due no later than January 8, 2020; however, was not completed until January 28, 2021. A treatment plan update was completed on March 29, 2021 and the next update was due no later than May 28, 2021; however, was not completed until June 14, 2021. The next was due no later than August 14, 2021; however, was not completed until August 23, 2021.
Client #2 was admitted on July 7, 2020 and was still active at the time of the inspection. A treatment plan update was completed on February 17, 2021 and the next update was due no later than April 16, 2021; however, was not completed until April 28, 2021. The next was due no later than June 27, 2021; however, was not completed until June 30, 2021.
Client #3 was admitted on January 20, 2021 and was still active at the time of the inspection. A treatment plan update was completed on May 12, 2021, and the next update was due no later than July 11, 2021; however, the next update was not completed until July 15, 2021. The next update was due no later than September 14, 2021; however, was not completed until September 22, 2021.
Client #4 was admitted on March 16,2021 and was still active at the time of the inspection. A treatment plan update was completed on June 2, 2021, and the next update was due no later than August 3, 2021; however, the next update was not completed until September 3, 2021.
Client #5 was admitted on September 17, 2020 and was discharged August 25, 2021. A treatment plan update was completed on April 22, 2021 and the next update was due no later than June 21, 2021; however, the next update was not completed until July 7, 2021.
Client #7 was admitted on May 4, 2020 and was discharged May 11, 2021. A treatment plan update was completed on November 2, 2020 and the next update was due no later than January 1, 2021; however, the next update was not completed until January 18, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/30/2021 Clinical Supervisor reviewed the 7 clients that had late treatment plan update with the appropriate staff. All staff were reminded that treatment plans are to be updated every 60 days regardless of whether the client is present or not. Client signature will be obtained at next possible meeting. Clinical Supervisor set up staff performance improvement plans with appropriate staff to correct this on 10/07/2021. |