Observations
Based on a review of nine personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee 6 received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.Employee #6 was hired as a counselor on November 4, 2019 and was due to have the communicable disease trainings no later than November 4, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training until January 21-22, 2021. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
One citation was received for an employee completing their HIV training outside of the 1 year mark. This employee did receive the training so no additional action steps need taken to address this.
Executive Director, Leanne Byerly, will ensure all required DDAP trainings are completed within employees 1 year of employment. ED will utilize DDAP TMS website to locate available trainings, including DDAP trainings that are hosted in house at Pyramid Healthcare. ED will ensure training plans of all employees are being monitored monthly to track progress. All employees were also provided another copy of required DDAP trainings that need to be completed during their first year of employment on 9/24/21 to serve as a reminder.
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