Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to provide documentation of HIV/AIDS training in three of six personnel records and TB/STD training in one of six personnel records.
The findings include:
Seven personnel records were reviewed on February 10, 2010. Six personnel records were required to have documentation of HIV/AIDS and TB/STD training. One counselor was hired in December of 2009 and does not need documentation of communicable disease training until December of 2010. The facility did not provide documentation of the required HIV/AIDS training in personnel records # 5, 6 and 7 or the required TB/STD training in personnel record # 5.
Employee # 5 is a Certified Registered Nurse Practitioner and was hired on June 8, 2004. HIV/AIDS and TB/STD training was due to be completed no later than June 8, 2006. The facility failed to provide documentation of HIV/AIDS and TB/STD training within two years of employment, as required by regulation.
Employee # 6 is a Licensed Practical Nurse and was hired December 3, 2007. HIV/AIDS training was due to be completed no later than December 3, 2009. The facility failed to provide documentation of HIV/AIDS training within two years of employment, as required by regulation.
Employee # 7 is the Medical Director and was hired June 26, 2006 and graduated from medical school prior to March of 1994. HIV/AIDS training was due to be completed no later than June 26, 2008. The facility failed to provide documentation of HIV/AIDS training within two years of employment, as required by regulation.
The facility director was interviewed on February 10, 2010 at approximately 2:00 PM. The facility director confirmed that there was no documentation of HIV/AIDS training in personnel records # 5, 6 and 7 or TB/STD training in personnel record # 5. None of these employees were available to interview. The facility director contacted employee # 5 to obtain documentation. Employee # 5 faxed training information to the facility director; but this information did not include a course curriculum, proof of completion or the number of training hours.
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Plan of Correction
The facility failed to provide documentation of HIV/AIDS training in three of six personnel records and TB/STD training in one of six personnel records. It is the responsibility of the facility to insure that all employees complete the required trainings and provide verification documentation to be included in the employee training file.
The identified employees will be responsible to schedule, attend and provide documentation of the trainings within the next 6 months or earlier if available.
It is the responsibility of the Facility Director to monitor those employees throughout this process. In addition, the Facility Director is responsible to monitor all future employees regarding compliance with this regulation and will develop a data base for that purpose.
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