Observations
Based on a review of personnel records, the facility failed to ensure a supervisor received the minimum of at least 4 hours of TB/STD and other health related topics within the first two years of employment in one of one record.
Staff #3 was hired as a clinical supervisor on January 14, 2022 and still employed at time of inspection. Staff #3 was due to have the communicable disease trainings no later than January 14, 2024. There was no documentation provided of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In a review of factors contributing to this it was determined that the affected staff had scheduled a TB/STD training within the required timeframe that was then cancelled by the trainer.
Per feedback proffered by our licensing representative during the review, division leadership has developed an internal training using the minimum content requirements outlined in DDAP Licensing Alert 6-97 for delivery to internal staff on a twice/year basis. The first of these trainings is scheduled to occur in November of 2024, and the second in April of 2025. They will continue at that frequency and as-needed to ensure full compliance with all training requirements. Timely completion of training requirements will remain the purview of our Training Coordinator who will continue to generate bi-annual training reports to Clinical Supervisors for review.
Staff #3 attended the TB/STD training on April 16, 2024. |