Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members, as required by their own facility assessment. The assessment indicated that staff should be trained to meet the needs of all residents, including specific competencies such as dementia care, infection control, and abuse prevention. However, the facility did not have a formal policy or procedure for new staff orientation or ongoing annual training for existing staff. When requested, the Director of Nursing (DON) was unable to provide documentation of such policies or procedures. A review of training transcripts for selected staff members, including LPNs, RNs, and CNAs, revealed that required training topics such as effective communication, resident rights, abuse/neglect/exploitation, QAPI, infection control, compliance and ethics, and behavioral health were not completed either at hire or annually. The facility relied on an online training platform (Relias) for staff education, but not all required modules were included in the training plan, and not all staff had completed the necessary training. Sign-in sheets and agendas from staff meetings did not cover the required topics, and not all selected staff had evidence of attendance. Despite the facility's claim that all employees are registered in Relias and assigned mandatory training modules upon hire, the documentation provided did not demonstrate that all required training was completed by the staff reviewed. The facility also lacked a formal, documented policy and procedure for both onboarding and annual training, as well as evidence that all required training topics were addressed for all staff members.