Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide required training on Compliance and Ethics for four out of ten 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 March 14, 2025, mandates that all personnel receive education and training on various topics, including the compliance and ethics program standards, policies, and procedures. This training is required annually for organizations operating five or more facilities. However, documentation revealed that Nurse Aide Employee E11, Nurse Aide Employee E15, Registered Nurse Employee E16, and Registered Nurse Employee E19 did not receive the necessary in-service education on Compliance and Ethics within the specified timeframes. During an interview on April 18, 2025, the Nursing Home Administrator confirmed the facility's failure to provide the required training for these staff members. The deficiency was identified based on the absence of documented training records for the specified employees, despite the facility's policy requiring such training. This oversight indicates a lapse in the facility's adherence to its compliance and ethics training program, as outlined in the regulatory requirements.
Plan Of Correction
Immediate Intervention: All nursing staff were provided with Compliance and Ethics training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed the training platform and Compliance and Ethics training discovered that 0946 was not uploaded to the training platform. It has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0946 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.