Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment in one of two records.Staff #3 was hired as a counselor on June 5, 2022 and was still in this position at the time of the inspection. Staff # 3 was due to receive communicable disease trainings no later than June 5, 2023. Training certificates in Staff #3 ' s record showed that a 4-hour TB/STD training was completed on October 2, 2023, which was past Staff #3 ' s first year of employment in their position as counselor. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employees will document attempts to enroll in required trainings before their first year of employment is up. Documentation with enrollment attempts will be kept on file to demonstrate staff dedication to meeting said deadline(s). Any staff found to be within non-compliance at first year of hire will be held accountable in accordance with facility policy on corrective action. Program facility and project director will be responsible for ensuring corrective action is implemented and enforced. FY 23-24 non-compliance has been addressed by project and facility director. Employee(s) has completed required training as outlined in observation #0067 |