Observations
Based on a review of personnel records on October 2, 2009, and a conversation with the director on October 26, 2009, the clinical supervisor failed to complete a core curriculum training in clinical supervision.
The findings include:
Employee #3 was hired by the facility on February 25, 2002 and promoted to clinical supervisor on November 5, 2007. As of the date of the personnel record review on October 2, 2009 and the date of the conversation with the director on October 26, 2009, employee #3 failed to complete a core curriculum training in clinical supervision.
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Plan of Correction
Clinical Supervisor, Vonzell Wade (employee #3) will attend core curriculum clinical supervision training on December 7-11 2009 in Cranberry, PA. Program Director, Marnie Hall and Human Resources Coordinator, Melissa Larimar will assure compliance by January 1, 2010. |
Observations
Based on a review of personnel records, a review of the facility summary report, and a conversation with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training for seven of fifteen personnel.
The findings include:
Six personnel records were reviewed on October 2, 2009. One personnel record was reviewed on October 27, 2009. The facility summary report was reviewed on October 26, 2009. Fifteen personnel were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in personnel records # 8, 9, 10, 11, 12, 13, 14 and 15.
Employee # 8 is a counselor and was hired August 25, 2008. HIV/AIDS and TB/STD training was to be completed within one year of hire, by August 25, 2009. The facility failed to provide documentation of TB/STD training as of October 27, 2009.
Employee # 9 is a counselor and was hired September 15, 2008. HIV/AIDS and TB/STD training was to be completed within one year of hire, by September 15, 2009. The facility failed to provide documentation of TB/STD training as of October 27, 2009.
Employee #10 is a support staff and was hired July 2, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by July 2, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of October 27, 2009.
Employee #11 is a support staff and was hired July 30, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by July 30, 2009. The facility failed to provide documentation of HIV/AIDS training as of October 27, 2009.
Employee #12 is a support staff and was hired August 14, 2006. HIV/AIDS and TB/STD training was to be completed within two years of hire, by August 14, 2008. The facility failed to provide documentation of HIV/AIDS training as of October 27, 2009.
Employee #13 is a support staff and was hired April 23, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by April 23, 2008. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of October 27, 2009.
Employee #14 is a support staff and was hired February 21, 2005. HIV/AIDS and TB/STD training was to be completed within two years of hire, by February 21, 2007. The facility failed to provide documentation of TB/STD training as of October 27, 2009.
Employee #15 is a support staff and was hired September 24, 2007. HIV/AIDS and TB/STD training was to be completed within two years of hire, by September 24, 2009. The facility failed to provide documentation of HIV/AIDS training as of October 27, 2009.
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Plan of Correction
Employee #8,9,10,13,14 will attend STD/TB training on December 15, 2009. Employees #10,11,12,13 and 15 will attend HIV/AIDS training on February 16, 2010. Program Director, Marnie Hall and Human Resources Coordinator, Melissa Larimar will assure compliance by March 1, 2010.
Human Resources will obtain DOH's curriculum for STD/TB training and HIV/AIDS training and assign a Pyramid Healthcare RN to administer these trainings to assure continued compliance with this requirement by March 1, 2010. |
Observations
Based on a review of the fire drill record log on October 26, 2009, and a discussion with the facility director and the maintenance supervisor on October 26, 2009, the facility failed to complete a fire drill for the month of May 2009.
The findings include:
The facility failed to complete a fire drill for the month of May 2009. This was confirmed by the facility director and the maintenance supervisor on October 26, 2009.
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Plan of Correction
Fire Drills will occur monthly as required by Ridgeview maintenance. Program Director, Marnie Hall and Director of Facility Maintenance, Ed Helms will assure compliance with this requirement ongoing beginnning immediately. |