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 #5 was hired as counselor on June 1, 2023 and was still in that position at the time of the inspection. Her tuberculosis, sexually transmitted diseases and other health related topics training was due no later than June 1, 2024; however, none was completed.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to be sure that a Counselor received a minimum of 4 hours of TB/STD/HEP training within the first year of employment to be compliant with the regulations concerning training on health- related topics.
To correct this deficiency, the counselor completed the 4-hour DDAP training on TB/STD/Hepatitis on 09/16/2024 and the certificate can be forwarded to the DDAP upon request.
To prevent the re-occurrence of this deficiency, the newly hired Clinical Supervisor and the Quality Assurance Coordinator will develop and maintain training schedules with Counselors. This will ensure the counselors and support staff are meeting the DDAP requirements for the training year and obtaining health-related required trainings. |