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 three of nine personnel.The findings include:Twelve personnel and training records were reviewed on November 1, 2010. The facility summary report was also reviewed on November 1, 2010. Nine personnel were required to have documentation of the mandatory HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for employees # 8, 11, and 12.Employee # 8 is a counselor and was hired on August 20, 2008, and was promoted on June 1, 2009. HIV/AIDS and TB/STD training was to be completed within one year of hire, or by August 25, 2009. The facility failed to provide documentation of TB/STD training for this employee.Employee #11 is a support staff and was hired October 28, 2002. HIV/AIDS and TB/STD training was to be completed within two years of hire, or by October 28, 2004. The facility failed to provide documentation of TB/STD training for this employee.Employee #12 is a support staff and was hired September 9, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, or by September 9, 2010. The facility failed to provide documentation of HIV/AIDS training for this employee.A discussion with the facility director on November 1, 2010, confirmed that the employees, # 8, 11, and 12 did not have documentation of the required training.
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Plan of Correction
Employee #8 is scheduled for HIV/AIDS training on 12-2-2010.
Employee #11 and #12 are scheduled for TB/STD training on 12-8-2010
Compliance will be monitored by the human resource coordinator, the clinical supervisor and the program director through quarterly training reviews.
The information will be reviewed by the program director at staff meetings and by the staff's respective supervisor during documented supervision meetings.
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