Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Employee #7 was hired as a counselor on March 5, 2024. His training was due no later than March 5, 2025; however, it was not completed until April 11, 2025.
This findings was reviewed with the facility staff during the licensing process.
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Plan of Correction
CCARS Director verbally retrained all staff immediately following the licensing visit on 9/22/25 regarding the necessity of completing all required trainings within the mandated timeframes set by DDAP regulations, including Communicable Disease trainings. Staff understand that their position may be in jeopardy if found to not be in compliance going forward. Director will check in with all staff at regular clinical and staff meetings to ensure ongoing compliance. Employee #7 completed HIV training on 4/11/24.CCARS to be in full compliance by 10/6/2025. |