Observations
Based on a review of the Staffing Requirements Facility Summary Report that the facility submitted as part of the presubmission process and a review of facility records conducted during the onsite inspection, the facility failed to ensure that all of the staff of the facility received the required training in communicable disease. Staff Person #4 was hired as a counselor on April 12, 2016. At the time of the onsite inspection there was no documentation that the staff person had received 4 hours of training in TB/STDs. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Staff Person #4 completed required training on June 19th, 2017.
Moving forward, the program plans on implementing the following system to ensure ongoing compliance:
Program Director created a training plan "spreadsheet" for new hires that has listed all mandatory trainings and their due dates. This spreadsheet will allow the Administrative Assistant and Program Director to ensure that all necessary trainings are scheduled and/or complete.
Program Director will review the training schedule during monthly supervision with each counselor.
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. |