Observations
The plan of correction follow up inspection was conducted on May 26, 2011. The Department of Health approved plan of correction for this deficiency gave the facility until May 27, 2011 to make the necessary corrections. This was not reviewed during the plan of correction follow up inspection. The facility should respond with the plan of correction originally approved by the Department. The citation was carried forward and read as follows:
Based on a review of personnel training records and an interview with the facility director and human resources director, the facility failed to provide documentation of communicable disease training in thirteen of twenty personnel training records.
The findings include:
Twenty-eight personnel training records were reviewed on December 13 - 15, 2010. Twenty personnel training records were reviewed for documentation of communicable disease training. Twenty personnel training records were required to have documentation of communicable disease training. Per regulation, 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 a 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.
The facility did not provide documentation of HIV/AIDS and TB/STD training in personnel training records # 18, 19, 20 and 24. The facility did not provide documentation of TB/STD training in personnel records #12, 17, 22, 23, 25, 26, 27 and 28.
Employee # 12 is a counselor and was hired on December 8, 2008. TB/STD training was due to be completed no later than December 8, 2009. The facility failed to provide documentation of TB/STD training for employee # 12.
Employee # 17 is support staff and was hired October 29, 2007. TB/STD training was due to be completed no later than October 29, 2009. The facility failed to provide documentation of TB/STD training for employee # 17.
Employee # 18 is support staff and was hired January 21, 2008. HIV/AIDS and TB/STD training were due to be completed no later than January 21, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 18.
Employee # 19 is support staff and was hired October 22, 2007. HIV/AIDS and TB/STD training were due to be completed no later than October 22, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 19.
Employee # 20 is support staff and was hired January 2, 2008. HIV/AIDS and TB/STD training were due to be completed no later than January 2, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 20.
Employee # 21 is support staff and was hired September 29, 2008. TB/STD training was due to be completed no later than September 29, 2010. The facility failed to provide documentation TB/STD training for employee # 21.
Employee # 22 is support staff and was hired January 7, 2000. TB/STD training was due to be completed no later than January 7, 2002. The facility failed to provide documentation of TB/STD training for employee # 22.
Employee # 23 is support staff and was hired October 15, 2007. TB/STD training was due to be completed no later than October 15, 2009. The facility failed to provide documentation of TB/STD training for employee # 23.
Employee # 24 is support staff and was hired October 13, 2007. HIV/AIDS and TB/STD training were due to be completed no later than October 13, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 24.
Employee # 25 is support staff and was hired September 1, 2005. TB/STD training was due to be completed no later than September 1, 2007. The facility failed to provide documentation of TB/STD training for employee # 25.
Employee # 26 is a counselor and was hired on January 14, 2008. TB/STD training was due to be completed no later than January 14, 2009. The facility failed to provide documentation of TB/STD training for employee # 26.
Employee # 27 is a counselor and was hired on December 29, 2008. TB/STD training was due to be completed no later than December 29, 2009. The facility failed to provide documentation of TB/STD training for employee # 27.
Employee # 28 is a counselor and was hired on March 24, 2008. TB/STD training was due to be completed no later than March 24, 2009. The facility failed to provide documentation of TB/STD training for employee # 28.
The facility director was interviewed on December 20 - 21, 2010 and confirmed that documentation of communicable disease training could not be located for these employees. The human resources director was interviewed on December 15, 2010 and confirmed that documentation of communicable disease training was not available in these personnel training records.
This is a repeat citation.
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Plan of Correction
Individual staff who were out of compliance for HIV/AIDS and/or TB/STD training will be required to attend training no later than 5/27/11. Clinical Managers and Supervisors will monitor for compliance. |
Observations
Based on a review of client records and an interview with the clinical supervisor, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of two client records.
The findings include:
Eighteen client records were reviewed on May 26, 2011. Two records were required to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 8.
In client record # 8, the client was admitted into treatment on April 25, 2011 and was involuntarily terminated from the project on May 6, 2011. There was no documentation of written notification to the client, at the time of the licensing inspection follow up on May 26, 2011.
The clinical supervisor was interviewed on May 26, 2011. The clinical supervisor reviewed the client record and verified that an involuntary termination notice was not included in client record # 8.
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Plan of Correction
All staff who complete discharge paperwork will be retrained on the Termination of Treatment form by 7/12/2011. The Director sent a memo to these same staff reminding them of this requirement on 6/21/2011. Clinical Managers and the Therapy Office Administrative Assistants will monitor for compliance. |