Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that all personnel received at least 4 hours of TB/STD and other health related topics training, using a Department approved curriculum, within the regulatory time frames.
The findings include:
The facility's SRFSR form, completed by the Project, was reviewed prior to July 10, 2014. The facility's SRFSR form listed one employee, # 7, as not having completed one of the mandatory trainings within the regulatory time frames. The facility failed to ensure that employee # 7 completed one of the mandatory trainings within the regulatory time frames.
Employee # 7 was hired as an Addiction Recovery Assistant on April 12, 2010. STD/TB training was due to be completed no later than April 12, 2012. Employee # 7 was not listed on the SRFSR form as having completed STD/TB training.
The findings were confirmed during an interview with the Vice President of Behavioral Health Services on July 11, 2014.
This is a repeat citation. The facility was cited on August 21, 2013 for noncompliance with this standard.
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Plan of Correction
All current employees including employee #7 will complete mandatory trainings on or before November 30, 2014, the nursing supervisor will insure that the training is completed. All LPN's will be scheduled for mandatory training durning new employee orientation. The Program Directors and the Nursing supervisor will monitor all new hires on a monthly basis to ensure that new hires complete mandatory training during new employee orientation. |