Failure to Provide Annual Ethics Training to Staff
Penalty
Summary
The facility failed to provide mandatory annual ethics training to 7 out of 23 employees reviewed, including housekeeping, certified nursing assistants, registered nurses, and licensed vocational nurses. Personnel records for these staff members showed no evidence of ethics training being completed within the previous 12 months, despite their varying hire dates. The HR Coordinator was responsible for initiating monthly in-service trainings and providing them to department heads, who were then expected to present the trainings to their staff. However, the records indicated that the required annual ethics training was not completed for these employees. Interviews with the HR Coordinator, DON, and Administrator confirmed that the process for delivering and verifying in-service trainings relied on department heads to present the material and the HR Coordinator to verify completion. The facility's policy required an educational calendar that included compliance and ethics training, but the lack of documentation in personnel files demonstrated that this requirement was not met for the identified staff members.