Failure to Provide Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide required Compliance and Ethics training to all staff members upon hire and did not include compliance and ethics in its ongoing in-service education. Record reviews of the Required In-Service Book and Facility Assessment showed that in-services covered topics such as dementia/behavioral training, resident rights, infection control, emergency response, abuse and neglect, misappropriation of property, disaster drills, staff burnout, oral hygiene, lock out tag out, elopement, and coronavirus, but did not include compliance and ethics. Interviews with the Administrator confirmed that if a topic was not listed in the in-service book, it was not covered, and the Administrator did not respond when specifically asked about ethics training. Further review of employee files for a CNA and an LPN revealed no documentation of Compliance and Ethics training upon hire, with only other topics such as abuse, neglect, misappropriation of property, burnout, enteral feeding, tracheostomy care, and suctioning acknowledged. Staff interviews confirmed that in-services were limited to the topics listed and did not include compliance and ethics. This lack of training was consistent across staff roles and was confirmed by both documentation and staff testimony.