Observations
The facility failed to document HIV/AIDS and TB/STD training in three of three personnel/training records reviewed on February 24, 2020.Employee # 5 is support staff and was hired on August 21, 2017. There was no documentation of HIV/AIDS and TB/STD training for employee # 5.Employee # 6 is support staff and was hired on April 3, 2017. There was no documentation of HIV/AIDS and TB/STD training for employee # 6.Employee # 7 is support staff and was hired on January 2, 2018. There was no documentation of TB/STD training for employee # 7.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director during new employee orientation will register all new employees for the mandated training during their orientation week. Upon completion of the mandated training the Clinical Director will make all copies of new staff certificates of completion and retain the certificates in the training file and personnel file of the employee. Employees 5,6 and 7 did receive their mandatory training on 3/23/20. Certificates of training have been put in each employees training file. All orientation forms have been updated to reflect mandated training and the Project Director will ensure all training are completed and all staff have certificates of completion in their file. |