Observations
Based on a review of staff records, the facility failed to ensure that staff persons received a minimum of 4 hours of tuberculosis, sexually transmitted diseases and other heath related topics training in one of eight applicable records.
Staff #7 was hired to the position of counselor on August 25, 2025 and was in this position at the time of review. Staff #7 was due to receive at least 4 hours of tuberculosis, sexually transmitted diseases and other heath related topics training no later than August 25, 2026. Staff #7 had not completed 4 hours of tuberculosis, sexually transmitted diseases and other heath related topics training as of the time of review.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
By 10/31/26, an internal department approved training will be developed for a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics that will be used internally within 365 days of hire if staff and volunteers are unable to attend a DDAP training.
Effective 9/23/26, Program Supervisor will keep a list of new hires and training dates to ensure all staff receive the required trainings within the regulatory requirements. |