Observations
Based on a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that staff persons and volunteers received a minimum of 6 hours of HIV/AIDS training using a Department approved curriculum.
The findings include:
Based on a supervisory review of the facility's licensing packet and the Staffing Requirements Facility Summary Report, the facility failed to provide documentation of the required 6 hours of HIV/AIDS training using a Department approved curriculum in two of two records, specifically # 2 and 5.
Employee # 2, the facility director, was hired September 25, 2006 and would have been required to complete 6 hours of HIV/AIDS training using a Department approved curriculum.
The Staffing Requirements Facility Summary Report as completed by the facility on October 12, 2011 indicated 6 hours of HIV/AIDS training in 1996. However, the information provided for employee # 2 did not include the provider of the HIV/AIDS training; therefore it could not be determined if the HIV/AIDS training was based on a Department approved curriculum.
Employee # 5, the medical director, completed medical school in 1992 and was hired January 2007. Employee # 5 would have been required to complete 6 hours of HIV/AIDS training using a Department approved curriculum.
The facility failed to provide documentation of the required 6 hours of HIV/AIDS training using a Department approved curriculum for employee # 5.
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Plan of Correction
Both Staff members will obtain 6 hours required HIV/AIDS training by attending the next offered local BDAP session, which the date is not yet known. Further, a letter of exception will be submitted by 4/1/2012 for review asking that the Physician be exempt from the requirement of attending the BDAP course, and instead allow the Physicians to seek Continuing Medical Education in HIV/AIDS as an equivalent.
All staff are and have been required to attend 6 hours of HIV training within their first year of employment. The staff files are reviewed quarterly by the Director, to assure compliance. Quarterly reviews will continue, and all staff will attend required training. The Clinical Director actually has 34 hours of HIV training from 1997-1998 from the PA AIDS Council. She was employed by the State of Pennsylvania to work as an AIDS Casemanager. This training was submitted, however, The Clinical Director is still required to obtain another 6 hour training which she will complete as soon as it is offered locally. The Director is responsible to assure all the above is implemented. |