Observations Based on a review of personnel and training records, the facility failed to ensure that staff persons and/or volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum as per the regulatory requirements in four of seven records reviewed.
The findings include:
Seven records were reviewed on December 4, 2013 for documentation verifying the completion of the mandatory HIV/AIDS and TB/STD training. Four out of seven applicable records lacked documentation that the training's were completed as per the regulatory requirements.
Employee #10, a counselor, was hired on 3/21/11. Employee # 10 was required to obtain 4 hours of TB/STD training by 3/21/12. TB/STD training was not documented as of the date of the inspection.
Employee # 11, a support staff person, was hired on 10/7/10. Employee # 11 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by 10/7/12. HIV/AIDS and TB/STD training was not documented as of the date of the inspection.
Employee # 12, a support staff person, was hired on 1/31/11. Employee # 12 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by 1/31/13. HIV/AIDS and TB/STD training was not documented as of the date of the inspection.
Employee # 13, a support staff person, was hired on 10/9/08. Employee # 13 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by 10/9/10. HIV/AIDS and TB/STD training was not documented as of the date of the inspection.
The findings were confirmed by the Facility Director.
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Plan of Correction To ameliorate the violation of standard 704.11(b)(1), the Clincal Director will review each employee training record twice yearly before the spring and fall training session. Each new staff member will be registered for upcomming seasonal trainings as they become available. On 1/8/14 all listed employees that did not attend the required trainings were registered to complete the required trainings. |