Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report submitted as part of the presubmission process and during the onsite inspection, the facility failed to ensure that all staff received the required training in communicable diseases.
Staff Person #6 was hired as a counselor on March 8, 2016. At the time of the onsite inspection there was no documentation that the staff person had received 6 hours of HIV/AIDS training and 4 hours of TB/STD training.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Staff Person #6 has resigned from the facility, therefore we will no longer have the opportunity to correct this specific person's plan, however below is our plan to prevent this from happening again.
Clinical Supervisor created a training plan "spreadsheet" for new hires that has listed all mandatory trainings and their due dates. This spreadsheet will allow the Clinical Supervisor to ensure that all necessary trainings are scheduled and/or complete.
Clinical Supervisor will review the training schedule during monthly supervision with each counselor.
Program Director will review the training schedule with the Clinical Supervisor during their monthly supervision for the next 3 months to ensure ongoing compliance.
Although the spreadsheet is created at the time of hire, it will be used for all staff, ongoing.
This system went into effect on June 19th, 2017. |