Observations
Based on a review of personnel records on June 9, 2010, as well as a conversation with the Project/Facility Director, the facility failed to ensure that all clinical staff receive at least four hours of TB/STD training within the first year of employment in one of three client records reviewed.
The findings include:
Three personnel records were reviewed on June 9, 2010. At least four hours of TB/STD training were required in three personnel records as of June 9, 2010. One out of three personnel records reviewed, #3, did not include documentation of at least four hours of TB/STD training. This staff person was hired on April 1, 2009. TB/STD training was required to be completed on or before April 1, 2010.
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Plan of Correction
The Project Director will assure that the Clinical Director receive four hours of TB/STD training as mandated. The Clinical Director will receive training by 9/10/2010 and a copy of the training certificate will be filed in the Clinical Director's personnel record. To assure that this deficiency does not reoccur the Project Director will conduct routine monthly inspection of all personnel files using a check list of required contents including mandated trainings. Staff that have not completed trainings as required will be issued an internal memorandum to complete required training and submit documentation within 45 days. The Project Director will maintain a tickler file to serve as a reminder of training documentation that may be due. Non compliance will result in suspension of duties until all requirements are met. |