Observations
Based on a review of personnel records, the facility failed to ensure employees received the minimum of at least 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first two years of employment in one of seven records.
Staff #5 was hired as a counselor technician on April 9, 2024, and still employed at the time of inspection. The communicable disease trainings were due no later than April 9, 2026. The HIV/AIDS training was completed April 30, 2026. The TB/STD was not completed at the time of inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward
staff training will be completed within the allotted time given. .Reminders will be sent to staff to remind when trainings are due
Facility Director will conduct chart
staff training review dates on a routine basis. |
Observations
Based on a review of client records, the facility failed to document follow-up information in four of four applicable records.
The facility's policy and procedures state telephone follow-ups are completed three, seven, and thirty days after discharge.
Client #1 was admitted to the residential level of care on May 11, 2026, and discharged May 18, 2026. The three-day follow-up was due no later than May 21, 2026; however, it was completed on May 28, 2026. The seven-day follow-up was due no later than May 25, 2026; however, it was completed on May 28, 2026. The thirty-day follow-up was due no later than June 18, 2026; however, it was completed on June 26, 2026.
Client #2 was admitted to the residential level of care on October 6, 2025, and discharged November 20, 2025. The three-day follow-up was due no later than November 23, 2025; however, it was completed on November 25, 2025.
Client #3 was admitted to the residential level of care on October 17, 2025, and discharged December 1, 2025. The seven-day follow-up was due no later than December 8, 2025; however, it was completed on December 9, 2025.
Client #4 was admitted to the residential level of care on March 3, 2026, and discharged April 14, 2026. The three-day follow-up was due no later than April 17, 2026; however, it was completed on May 28, 2026. The seven-day follow-up was due no later than April 21, 2026; however, it was completed on May 28, 2026. The thirty-day follow-up was due no later than May 14, 2026; however, it was completed on April 28, 2026.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 28, 2025, licensing inspection.
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Plan of Correction
Immediately and moving forward
client follow ups will be completed on a three, seven, and thirty days after discharge as stated in the facility policy .Reminders will be set in the EHR. Staff will also be trained on the follow up process effective immediately
Facility Director will conduct chart
audits on a routine basis. |