Observations
Based on a review of personnel records and a review of the Staffing Requirements Facility Summary Report, the facility failed to document that all staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training and other health related topics using a Department approved curriculum in six of ten employee records. The findings include:On April 18, 2012, ten employee records requiring documentation of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training was reviewed. The facility failed to ensure that six of ten employees received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training, specifically employees # 3, 4, 9, 10, 11, and 13.Employee # 3, the clinical supervisor, was hired on 9/5/07. HIV/AIDS and TB/STD training was to have been documented within the first year of employment or by 9/5/08. The facility failed to ensure that employee # 3 received the required 6 hours of HIV/AIDS and 4 hours of TB/STD training.Employee # 4, a counselor assistant, was hired on 1/18/11. HIV/AIDS and TB/STD training was to have been documented within the first year of employment or by 1/18/12. The facility failed to ensure that employee # 4 received the required 6 hours of HIV/AIDS and 4 hours of TB/STD training.Employee # 9, a counselor, was hired on 4/2/08. Documentation in the employee record indicated that 5.5 hours of HIV/AIDS training was obtained on 11/16/98, 5 hours of HIV/AIDS training on 4/2/02, and 4 hours of HIV/AIDS training on 4/7/09. The documented training's for employee # 9 failed to meet the requirement for a 6 hour training of HIV/AIDS using a Department approved curriculum. Employee # 10, a counselor, was hired on 6/25/09. HIV/AIDS and TB/STD training was to have been documented within the first year of employment or by 6/25/10. The facility failed to ensure that employee # 10 received the required 6 hours of HIV/AIDS and 4 hours of TB/ST training.Employee # 11, the DUI Evaluator, was hired on 10/30/09. HIV/AIDS and TB/STD training was to have been documented within the first 2 years of employment or by 10/30/11. The facility failed to ensure that employee # 11 received the required 6 hours of HIV/AIDS and 4 hours of TB/STD training.Employee # 13, the Receptionist, was hired on 9/5/08. HIV/AIDS and TB/STD training was to have been documented within the first 2 years of employment, or by 9/5/10. The facility failed to ensure that employee # 12 received the required 6 hours of HIV/AIDS and 4 hours of TB/STD training.In addition, the Staffing Requirements Facility Summary Report which was completed by the facility on 4/18/12 was reviewed. The Staffing Requirements Facility Summary Report included documentation supporting the above findings. The Facility Director confirmed the findings.
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Plan of Correction
Employee #3 completed STD/TB on 5/8/2008. Documentation of this will be made available for future inspections. However, HIV/AIDS training was not completed but scheduled for completion on 6/5/2012.
Employee #4 completed HIV/AIDS training on 11/3/2011 and TB/STB on 5/11/2012. Documentation of this will be made available for future inspections.
Employee #9 completed TB/STD on 3/19/2010. Documentation of this will be made available for fufutre inspections. However, HIV/AIDS training has not been completed but will be in-house utilizing the Pennsylvania Department of Health Approved HIV/AIDS Curriculum no later than 7/31/2012.
Employee #10 completed HIV/AIDS on 9/27/2010. Documentation of this will be made available for fufutre inspections. However, TB/STD training has not been completed but will be completed in-house utilizing the Pennsylvania Department of Health Approved TB/STD Curriculum no later than 7/31/2012.
Employee #11 and #13 has not completed either training. However, HIV/AIDS and TB/STD training will be completed in-house utilizing the Pennsylvania Department of Health Approved HIV/AIDS and TB/STD Curriculum in two seperate sessions no later than 7/31/2012.
Facility director will ensure that employees complete training on specified dates indicated above. The facility director will also prevent this from re-occurring by setting up tickler files for new hired employees with requirements to complete these trainings within one year of hired date, alerts will be set at 6 months and 9 months, and employees that are require to complete within 2 years of hired date, at 12 months and 18 months, in order ensure completion. |