Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff.
The findings include:
The SRFSR was reviewed on June 10, 2015 for staff compliance with required HIV/AIDS and TB/STD training. One out of one staff for which the training was due, specifically record # 3, did not received the training within the required timeframe. Employee # 3 accepted the position of clinical supervisor on September 9, 2013. Training was due by September 9, 2014. HIV/AIDS training was not completed until November 14, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The D&A Director is responsible for ensuring that all new clinical staff receive the 4 hour TB/STD training and the 6 hour HIV training within one year of hire. Moving forward, the D&A Director will review all staff training plans at least once per quarter for timely compliance with this regulation. If an outside DDAP approved TB/STD and/or HIV training is unavailable within the one year of hire, the D&A Director will conduct these trainings utilizing DDAP approved curriculum with the appropriate staff in order to ensure compliance with this regulation. |