Observations
Based on a review of personnel records and staff interviews, the facility failed to document HIV/AIDS and/or TB/STD training, as required by regulation..The findings include:On September 28 & 29, 2011 eleven staff records requiring documentation of HIV/AIDS and/or TB/STD trainings were reviewed . The facility failed to document HIV/AIDS training and/or TB/STD training in five of eleven records reviewed, specifically records # 7, 8, 9, 10 and 11.Employee # 7 is a counselor and was hired on September 7, 2010. A Department approved curriculum in HIV/AIDS training was due to be completed no later than September 7, 2011. This training was not completed at the time of the inspection, September 28 & 29, 2011.Employee # 8 is a counselor and was hired on May 26, 2009. A Department approved curriculum in STD/TB training was due to be completed no later than May 26, 2010. This training was not completed at the time of the inspection, September 28 & 29, 2011.Employee # 9 is a counselor and was hired on May 12, 2010. A Department approved curriculum in HIV/AIDS and STD/TB training was due to be completed no later than May 12, 2011. This training was not completed at the time of the inspection, September 28 & 29, 2011.Employee # 10 is a nurse and was hired on August 21, 2009. A Department approved curriculum in STD/TB training was due to be completed no later than August 21, 2011. This training was not completed at the time of the inspection, September 28 & 29, 2011.Employee # 11 is a security guard and was hired on June 4, 2007. A Department approved curriculum in HIV/AIDS training was due to be completed no later than June 4, 2009. This training was not completed at the time of the inspection, September 28 & 29, 2011.An interview with the clinical supervisor took place on September 29, 2011, at which time it was confirmed that the aforementioned staff records did not have documentation of the required TB/STD and/or HIV/AIDS training.
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Plan of Correction
The facility did not provide for employees to complete required HIV/AIDS or TB/STD trainings within the necessary time frame.
It is the responsibility of the facility to ensure that all employees complete required trainings within the specified time frames.
The Clinical Supervisor will be responsible to see that all staff are registered, attend and complete the required trainings by the corrective action date. Further, it is the responsibility of the clinical supervisor to monitor compliance by developing a tracking tool for any new employee of Pinnacle. This tool will allow the supervisor to monitor on an ongoing basis all training needs and completed trainings.
The Facility Director will provide ongoing oversight in this area. |