Observations
Based on a review of personnel and training records, the facility failed to ensure that staff persons and/or volunteers received 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 as per the regulatory requirements in one of thirteen records reviewed.
The findings include:
Thirteen were reviewed on August 20, 2014 for documentation verifying the completion of the mandatory HIV/AIDs and TB/STD trainings. One out of thirteen lacked documentation that the trainings were completed as per the regulatory requirements.
Employee # 8, a counselor, was hired on May 28, 2013. Employee #8 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by May 28, 2014. The training was not documented as of August 20, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee number 8 will attend 6 hours of HIV/AIDS training and 4 hours of TB/STD training and provide documentation of completion to the Clinical Supervisor by November 1, 2014. The employee is scheduled for HIV/AIDS on Friday 9/19/14 and TB/STI on Friday 10/3/14. Compliance will be monitored by the Clinical Supervisor via weekly supervision. The Clinical Supervisor will conduct biannual audits of Personnel files for all CAD staff members to ensure compliance and timely progress for completion of trainings. This will be addressed as part of staffs' monthly supervision with the Clinical Supervisor. |