Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training to seven out of nine staff members, as evidenced by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including behavioral health training. However, documentation revealed that several employees, including nurse aides, environmental services, dietary staff, and a maintenance director, did not receive the necessary behavioral health in-service education within the specified timeframes after their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of behavioral health training for these staff members. This deficiency was identified in the context of the facility's broader training requirements, which also include communication, resident rights, infection prevention, and other critical areas. The failure to provide behavioral health training was noted alongside a separate issue regarding infection prevention and control training, which was also not provided to six of the 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 Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.