Deficiency in Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, as required by §483.95. This deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. Specifically, the facility's policy on 'Training Requirements,' last reviewed on October 20, 2024, mandates the development and maintenance of an effective training program for all staff. However, the facility did not adhere to this policy for four nurse aides, identified as Employees E1, E3, E4, and E5. The training records for these employees were either incomplete or missing, indicating a lack of documented training within the specified timeframe. Employee E1, hired on October 9, 2022, had no documented dates or times of training in their education file. Employee E3, hired on October 11, 2004, had no education file or documentation of completed education from October 11, 2023, through October 11, 2024. Employee E4, hired on October 11, 2005, had a '12-hour in-service packet' in their file, but no dates confirmed the training occurred within the required period. Similarly, Employee E5, hired on November 12, 2013, had a '12-hour in-service packet' without dates confirming the training occurred between November 12, 2023, and November 12, 2024. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide training on infection prevention and control for six of nine staff members.
Plan Of Correction
No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.