Failure to Provide Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide training on its compliance and ethics program to all sampled Certified Nursing Assistants (CNAs), as evidenced by a review of training records and staff interviews. Specifically, five CNAs hired between 2008 and 2024 had no documented evidence of receiving compliance and ethics training. The Interim Assistant Director of Nursing/Quality Assurance Quality Improvement/Infection Control Nurse confirmed that no compliance and ethics training modules were assigned in the Relias system, and both the previous and current compliance officers had not provided such training. Staff interviews further confirmed that neither CNAs nor Licensed Nurse Aides had received training on the facility's compliance and ethics program. Additionally, a review of a staff meeting agenda and attendance records did not show that compliance and ethics were discussed, and not all staff attended the meeting. The facility's Compliance and Ethics Program policy requires orientation and annual refresher training for all associates and affiliates, but this requirement was not met for the sampled staff. This lack of training placed residents at risk for non-compliant and unethical treatment, as staff were not educated on the facility's expectations or their responsibilities regarding compliance with laws.