Failure to Ensure Required Staff Training for New and Existing Employees
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, as evidenced by the lack of required annual and initial trainings for 11 out of 23 employees reviewed. Personnel records showed missing documentation of mandatory trainings such as communication, QAPI, ethics, falls, HIV, restraint, emergency preparedness, and behavioral health for various staff members, including housekeepers, certified medication aides, certified nursing assistants, licensed vocational nurses, registered nurses, dietary aides, and the dietary manager. Specifically, the dietary manager did not receive required trainings upon hire, and several other staff members lacked evidence of receiving annual trainings as outlined in facility policy. Interviews with the HR Coordinator, DON, and Administrator confirmed that the facility's process involved the HR Coordinator initiating monthly in-service trainings, which were then distributed to department heads to present to their staff. However, the system relied on department heads to ensure completion, and the HR Coordinator to verify compliance, which did not consistently occur. The HR Coordinator acknowledged uncertainty regarding why all required trainings for the dietary manager were not completed upon hire and recognized the importance of staff receiving both initial and annual trainings. A review of the facility's in-service education policy revealed a comprehensive list of required training topics to be covered annually or upon hire, including but not limited to communication, QAPI, infection control, emergency preparedness, ethics, and abuse prevention. Despite this policy, the facility did not ensure that all staff received the necessary trainings, as evidenced by the gaps found in personnel records and confirmed by staff interviews.