Observations
Seven personnel records were reviewed on October 20-21, 2016, the facility failed to provide documentation of the required HIV/AIDS and TB/STD training in personnel records, #4, 5 and 6.
Employee #4, a counselor, was hired July 17, 2014. HIV/AIDS and TB/STD training was due to be completed no later than July 17, 2015. The facility failed to provide documentation of TB/STD training as of the date of the licensing inspection.
Employee #5, a counselor, was hired June 29, 2015. HIV/AIDS and TB/STD training was due to be completed no later than June 29, 2016. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the licensing inspection.
Employee #6, a counselor, was hired August 16, 2015. HIV/AIDS and TB/STD training was due to be completed no later than August 16, 2016. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselor hired 7/17/14 did complete the Basic HIV. She has now completed TB/STD/Hepatitis since the survey, on 11/16/16. The other counselor also attended TB/STD/Hepatitis on 11/16/16 and is scheduled for 11/29 for Basic HIV. We attempt to get everyone in not only to the core courses within one year of hire, but into others that they need for their 25 annual credits. We will work with our SCA to formally request they bring a trainer to our site for new hires to attend.
At the time of all new hires we will get them scheduled with these courses within one year of hire for counselors and within two years of hire for all other staff when the courses are offered; or, have our SCA bring in a trainer at an earlier date to meet the deadline.
All staff have been reminded of these requirements by the Clinical Supervisor (Program Supervisor). The plan to utilize our SCA for access to local trainings has been immediately implemented. The Clinical Supervisor will monitor continuously with new hires for the applicable one year/two year time span to insure that if they cannot get registered for seating in an existing DDAP training upon hire and beginning of orientation, we will inform our SCA immediately. |