Observations
Based on a review of nine personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as the clinical supervisor on August 29, 2019 and was due to have the communicable disease trainings no later than August 29, 2020. There was no documentation in the personnel file for the completion of the HIV/AIDS training until January 21-21, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The training Department will coordinate with the Human Resources department and program management to ensure that all staff receive all required trainings in a timely manner. At the program level, the Program Director will review staff files on a Quarterly basis to ensure that training requirements are met. Additionally, the Quality Assurance department will conduct quarterly audits of the program, and the Compliance department will conduct at least annual audits of all plans of correction to ensure compliance. |