Observations
Based on a review of personnel and training records, a review of the facility summary report, and a conversation with the director, the facility failed to provide documentation of HIV/AIDS and TB/STD training for one of one personnel records.
The findings include:
Six personnel records and the facility summary report were reviewed on September 30 and October 1, 2010. One personnel record was required to have documentation of HIV/AIDS and TB/STD training. Five of the six records were not employed for one year and therefore were not applicable to have the documentation at the time of the review. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for personnel record # 6.
Employee # 6 is a counselor and was hired November 17, 2008. HIV/AIDS and TB/STD training was to be completed within one year of hire, by November 17, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training as of October 1, 2010.
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Plan of Correction
The Program Director and Human Resources will work with the PRN staff member who does not have the HIV/AIDS/TB & STD training to get her trained by January 31st 2011. The Program Director will also review trainings with all staff during staff meeting and individual supervision sessions to insure that all staff will be compliant with training requirements. |