Observations
Based on a review of personnel records, the facilty failed to document that staff persons and 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. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment in 6 of 13 personnel records.The findings include:Thirteen personnel records were reviewed on November 19 -20, 2015. Counselors and counselor assistants are to complete HIV/AIDS and TB/STD training within the first year of employment and all other staff within the first 2 years of employment. Staff records # 4, 9, 10, 11, 12 and 13 did not include documentation of HIV/AIDS and TB/STD training within the required timeframes for their position.Employee #4 was hired as a counselor on 6/23/14. HIV/AIDS and TB/STD training was due to be completed by 6/23/15. At the time of the inspection, employee #4 had not completed HIV/AIDS and TB/STD training.Employee #9 was hired as an administrative assistant on 2/25/13. HIV/AIDS and TB/STD training was due to be completed by 2/25/15. At the time of the inspection, employee #9 had not completed HIV/AIDS and TB/STD training.Employee #10 was hired as a monitor on 12/17/12. HIV/AIDS and TB/STD training was due to be completed by 12/17/14. At the time of the inspection, employee #10 had not completed HIV/AIDS and TB/STD training.Employee #11 was hired as a monitor on 10/15/12. HIV/AIDS and TB/STD training was due to be completed by 10/15/14. At the time of the inspection, employee #11 had not completed HIV/AIDS and TB/STD training.Employee #12 was hired as a monitor on 6/10/13. HIV/AIDS and TB/STD training was due to be completed by 6/10/15. At the time of the inspection, employee #12 had not completed HIV/AIDS and TB/STD training.Employee #13 was hired as a monitor on 8/19/13. HIV/AIDS and TB/STD training was due to be completed by 8/19/15. At the time of the inspection, employee #13 had not completed HIV/AIDS and TB/STD training.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As a response to the citation received during our recent survey, All identified staff, #4,#9,#10,#11,#12 and #13, will have the HIV/AIDS and TB/STD training completed by a department approved curriculum. This will be completed NLT March 1st 2016. In the future,to ensure that all trainings are completed we will enlist the support of the Assistant Director/Clinical, Assistant Director/Security Operations, the Administrative Assistant and I to review all staff's training progress in both Annual training plans and quarterly meetings specific to staff development. This will allow Administrators and Clerical staff assigned to tracking training hours to to discuss training progress and identify deficiencies with regard to meeting required training completion. A review of outstanding trainings due can then be addressed in regular supervision review sessions with individual staff to prevent any oversight that may occur and ensure that all staff remain on top of what trainings need to be completed. |