Failure to Ensure Completion and Documentation of Required Annual Staff Trainings
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 trainings for five employees, including a CNA, a dietary aide, a medication aide, the dietary manager, and the assistant director of nursing. Personnel records reviewed for these staff members showed missing documentation of annual trainings in key areas such as communication, ethics, resident rights, and behavioral health. The HR Coordinator confirmed that the facility used an online training platform (Relias) and that department heads were responsible for ensuring staff completed their assigned annual trainings, but records did not show completion of all required topics for the reviewed period. Interviews with the HR Coordinator, Administrator, and DON revealed that while the facility had processes in place for assigning and notifying staff of required trainings, there was a lack of oversight to ensure completion and documentation of all mandated annual trainings. Additionally, when requested, the facility was unable to provide a policy specifically addressing the required annual trainings in communication, resident rights, ethics, and behavioral health prior to the survey exit. The employee handbook referenced mandatory training but did not specify the required topics or provide evidence of compliance for the staff reviewed.