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 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 October 9, 2014. The facility's SRFSR form listed one employee, # 4, as not having completed one of the mandatory trainings within the regulatory time frames. The facility failed to ensure that employee # 4 completed one of the mandatory trainings within the regulatory time frames.
Employee # 4 was hired as a Counselor on May 6, 2013. TB/STD training was due to be completed no later than May 6, 2014. Employee # 4 was not listed on the SRFSR form as having completed TB/STD training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 4 has been scheduled to have TB/STD training on 2/20/2015 being provided by a DDAP approved trainer. To assure that all staff have all required training and they maintain the required amount of training hours the following plan has been instituted. All staff training files will be reviewed quarterly by the Program Director and Clinical Supervisor. All staff will be informed quarterly on the status of individual training hours during supervision with the Program Director or Clinical Supervisor.
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