Observations
Based on a review of personnel and training records, the facility failed to document that staff completed HIV/AIDS and TB/STD training within the required timeframe in 7 of 12 records.Staff #9 was hired as a counselor assistant on May 6, 2019. HIV/AIDS and TB/STD training was due to be completed by May 6, 2020. There was no documentation of HIV/AIDS or TB/STD training in staff record #9.Staff #10 was hired as a support staff on January 29, 2018. HIV/AIDS and TB/STD training was due to be completed by January 29, 2020. There was no documentation of TB/STD training in staff record #10.Staff #11 was hired as a support staff on February 18, 2019. HIV/AIDS and TB/STD training was due to be completed by February 18, 2021. There was no documentation of TB/STD or HIV/AIDS training in staff record #11. Staff #12 was hired as a support staff on January 21, 2019. HIV/AIDS and TB/STD training was due to be completed by January 21, 2021. There was no documentation of HIV/AIDS training in staff record #12. Staff #13 was hired as a support staff on November 4, 2019. HIV/AIDS and TB/STD training was due to be completed by November 4, 2021. There was no documentation of HIV/AIDS or TB/STD training in staff record #13. Staff #14 was hired as a support staff on May 20, 2019. HIV/AIDS and TB/STD training was due to be completed by May 20, 2021. There was no documentation of HIV/AIDS or TB/STD training in staff record #14. Staff #15 was hired as a support staff on Feburary 12, 2018. HIV/AIDS and TB/STD training was due to be completed by February 12, 2020. There was no documentation of HIV/AIDS training in staff record #15. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the August 28, 2020 and October 24, 2019 licensing inspections.
|
Plan of Correction
Gateway will be offering, per DDAP bulletin, HIV/AIDS training available quarterly to its employees. In addition, Gateway will utilize the online DDAP approved offerings for HIV/AIDS and TB/STD training.
The nursing supervisor will be providing training at Gateway Rehab and will use the DDAP curriculum for both HIV/AIDS, STD/TB. These trainings will be offered monthly.
The employees will be required to sign up and complete the next HIV/AIDS and TB/STD training.
In order to satisfy the deficiencies that we currently have, we have secured training for the employees listed below.
The following employees will be registered to attend Communicable Disease Training on the following dates:
Dec 1-2 (Virtual), Dec 8-9 (virtual), Jan 5-6 (virtual), Jan 10-11 (Virtual), and Feb 3-4 (Virtual).
Staff 9
Staff 10
Staff 11
Staff 12
Staff 13
Staff 14
Staff 15
The VP of Recovery Service reminded all staff present at the Enterprise Management Meeting of October 29, 2021 that Mandatory Communicable Disease Training (HIV/AIDS & TB/STD are required trainings and must be completed by counselors and counselor assistants within the first year of employment. All other staff must complete Communicable Disease Trainings within the first two years of employment and to share this licensure requirement with all applicable staff.
Because this is a repeat deficiency, the Compliance Officer and VP of Human Resources will be conducting a monthly audit of all "active" Training Records to ensure compliance with Mandatory Communicable Disease Training.
Counselors and Counselor assistants will be required to register and attend the HIV/AIDS & TB/STD Training that is offered immediately following their hire date. If this session is full then they will be required to register and attend the next HIV/AIDs & TB/STB Training.
Training Record Audit results will be forwarded to the Manager, Program Director, applicable Vice President for corrective action.
Staff that do not comply with this licensing requirement and their direct Manager will be subject to progressive discipline and will not be eligible for performance evaluation increases.
Training Record Audit results will also be shared at the Quarterly Compliance Meeting.
|