Observations
Based on a review of personnel records and the facility-submitted Staffing Requirement Facility Summary Report, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in two of two applicable personnel records reviewed.
Employee #3 was hired as a counselor on March 4, 2021. The HIV/AIDS training and the TB/STD training were due no later than March 4, 2022. However, neither training was completed at the time of the inspection.
Employee #7 was hired as a counselor on January 20, 2021. The HIV/AIDS training and the TB/STD training were due no later than January 20, 2022. However, neither training was completed at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
1)While the two identified staff did complete training through an external learning platform, the facility has created more comprehensive training modules based on the required curriculum outlined in DDAP Licensing Alerts 1-97 and 6-97.
2)To ensure all staff persons receive a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics, these new trainings have been added to all new hire training plans to facilitate prompt completion.
3)All Primary Therapists will complete a review of the newly developed HIV/AIDS and TB/STD training modules by 7/31/2022.
4)The Director of Quality & Regulatory Compliance will track training completion for staff and provide Department Managers on-going reports to monitor compliance. |