Observations
Based on a review of personnel records, the facility failed to ensure staff received at least 6 hours of HIV/AIDS and 4 hours of TB/STD within the first two years of employment in one of one applicable records.
Staff #1 was hired at the facility August 5, 2019 and still employed at time of inspection. Communicable disease training was due no later than August 5, 2021. There was no documentation provided for the completion of the trainings as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All training will be completed within the required timeframe.
The outstanding trainings for this individual will be completed as soon as they can be scheduled. This is anticipated to be no later than 12/31/26.
All staff members have an Individual Training Plan generated on their start date and then updated annually in January. This is reviewed with the staff member and signed to indicate that they understand the training requirements.
The Gaudenzia Compliance Department will conduct a review of all POC action items within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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