Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide required compliance and ethics training to nine staff members, as evidenced by a review of personnel in-service training records and staff interviews. The staff members, including nurse aides, a central supply employee, an activities assistant, a maintenance employee, a registered nurse, and an LPN, did not have documented training on compliance and ethics as required by the regulations. The training was supposed to occur annually, but records showed that these employees did not receive the necessary training within the specified time frames. During an interview, the Nursing Home Administrator confirmed the lack of compliance and ethics training for these staff members. The deficiency was identified based on the absence of documented in-service education for each employee within the required period, which varied according to their hire dates. This oversight indicates a failure to meet the regulatory requirements for staff development and compliance training, as outlined in the facility's compliance and ethics program.
Plan Of Correction
1. The facility will ensure employees receive Compliance and Ethics training on a yearly basis. 2. A full house employee file audit will be conducted to identify the training needs of each employee to ensure ongoing yearly training. 3. The Human Resources Director or designee will ensure that each employee of the facility receives Compliance and Ethics training on a yearly basis by reviewing their training courses prior to their performance appraisal due date. If the training has been inadvertently missed, the employee will be trained on the missed course prior to the performance appraisal being completed. 4. The Administrator or designee will review 5 employee files due for performance review each month to ensure yearly training is completed weekly x4 weeks. The QAPI committee will determine the need for further audits.