Observations
Based on a review of three personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee #3 was hired as a counselor on March 29, 2021 and was due to have the communicable disease trainings no later than March 29, 2022. The plan of correction from the May 16, 2022 annual licensing inspection, indicated that the employee would complete the training by June 2022. However, there was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
This is a repeat citation from the May 16, 2022 annual licensing inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee 3 was enrolled in the DDAP approved HIV/AIDS for Substance Abuse Professionals training in the Relias on 6/20/23. She will complete the training by 7/7/23.
The Clinical Supervisor will review employee training records quarterly as part of the individual training plan implementation process.
The Division Director will review individual training plans with the Clinical Supervisor during documented supervision sessions on a quarterly basis.
The Clinical Supervisor will collaborate with Counselors to ensure prompt enrollment into required training sessions.
The CQI Manager will review program training records as part of the quarterly physical site inspection process.
The CQI Manager will review all open Plans of Correction during the quarterly review process and will advise program management of identified deficiencies. |
Observations
Based on a review of client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in three of seven applicable records reviewed.
Client #2 was admitted on December 13, 2022 and was discharged on February 28, 2023. The treatment plan completed on December 13, 2022, indicated that the client was to receive one individual session per week; however, the record contained no documentation of individual sessions between January 5, 2023 and January 25, 2023.
Client #3 was admitted on October 7, 2022 and was discharged on March 17, 2023. The treatment plan update completed on February 21, 2023, indicated that the client was to receive one individual session per week; however, the record did not contain documentation of individual sessions between February 21, 2023 and the date of discharge.
Client #4 was admitted on May 27, 2022 and was discharged on January 6, 2023. The treatment plan updates completed on August 1, 2022 and September 1, 2022, indicated that the client was to receive one individual session per week; however, the record did not contain documentation that individual sessions were offered between September 2, 2022 and September 30, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients 2, 3, and 4 have been discharged from the program as of the date of inspection.
The Clinical Supervisor will use an internal spreadsheet to monitor the completion of treatment plans weekly.
The Clinical Supervisor will conduct supervision sessions with counselors to review client treatment attendance and to ensure the proper documentation of missed visits.
In cases where a client has an extended absence from service, the counselor will document weekly updates regarding the client's plan to re-engage with services.
The Clinical Supervisor will audit a sample of clinical charts monthly, to include a review of treatment plan updates. Any deficiencies noted will be addressed with specific clinicians in clinical supervision and corrections made within 3 days.
The Quality Assurance Department will conduct at least quarterly reviews to include audits of clinical records, the findings of which will be discussed with the program, and action steps developed. These reviews include monitoring of all Plans of Correction to ensure full implementation. |