Observations
Based on the review of personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of one applicable personnel record reviewed. Employee # 5 was hired as a counselor on February 3, 2025 and was due to have the HIV/AIDS training and the TB/STD training completed no later than February 3, 2026. The HIV/AIDS training was completed on April 2, 2026 and the TB/STD training was completed on February 20, 2026.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All training will be completed within the required timeframe.
All staff members have an Individual Training Plan generated on their start date that includes all required trainings for their position. This is reviewed with the staff member and signed to indicate that they understand the training requirements.
The Clinical Supervisor will review the Individual Training Plans on a quarterly basis for all staff. Staff who have upcoming training due dates within the next quarter will be reminded of this, the Supervisor will work with them to schedule training sessions prior to the due dates and will monitor to ensure full and timely completion.
If the staff member must cancel a training, they will work with the Clinical Supervisor to determine the next available date of the training.
If any issues are noted with unavailability of required training session opportunities, this will be addressed with the Division Director and the Regional Executive Director to assist in advocating with the training provider.
The Gaudenzia Compliance Department will conduct a review of all citations within 90 days to ensure full implementation, identify any barriers to implementation, and coordinate support, where needed.
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