Observations
Based on a review of eight personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that three employees received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor on May 9, 2019 and was due to have the communicable disease trainings no later than May 9, 2020. There was documentation in the personnel file that of the completion of the HIV/AIDS training did not happen until August 28, 2020.
Employee #4 was hired as a counselor on December 2, 2019 and was due to have the communicable disease trainings no later than December 2, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and no documentation of the completion of TB/STD training at the time of the inspection.
Employee #6 was hired as a counselor on February 24, 2020 and was due to have the communicable disease trainings no later than February 24, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and no documentation of the completion of TB/STD training at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Employee #3 was registered for a 4/2/20 HIV/AIDS training, the training was canceled.
Employee #4 was registered for a 4/22/20 HIV/AIDS training which was canceled and a 6/24/20 TB/STD training which was also canceled. Employee #4 completed HIV/AIDS training on 1/22/21 and TB/STD training on 2/23/21.
Employee #6 completed TB/STD training on 2/2/21 and HIV/AIDS training on 2/19/21.
Due to the pandemic, many PCS staff had difficulty completing the required trainings. The Director of Outpatient Services is currently working with the PCS Training Department to develop curriculum to be approved by DDAP so that in-house communicable disease trainings can be offered to PCS staff to ensure completion within the regulatory timeframes. |