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F0607
E

Failure to Ensure Contract Staff Receive Required Abuse Prevention Training

Honolulu, Hawaii Survey Completed on 05-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and fully implement policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility's policy did not address how contract or agency caregivers would receive the required abuse prevention training, except for a brief mention of burnout identification. A review of contract staff files revealed that four out of six contracted nursing assistants lacked evidence of having completed the required abuse prevention training, or the documentation provided was insufficient in content and validation. For example, some training only included minimal or irrelevant content, such as questions about child abuse or intimate partner violence, and others were not properly graded or did not cover all required elements. Interviews with facility leadership, including the ADON, Administrator in Training, CEO, and Human Resource Director, revealed inconsistent practices regarding the orientation and training of contract staff. The ADON admitted to signing off on orientation checklists without directly observing competency demonstrations and stated that only a limited portion of abuse training was provided by the facility, with the expectation that agencies would cover the rest. However, there was no verification that agency-provided training met facility or regulatory requirements. The HRD confirmed that review of agency training content was not part of her process, leaving gaps in oversight. A review of contracts with staffing agencies further demonstrated that most agreements did not specify requirements for abuse prevention training or orientation to facility policies. Some contracts placed the responsibility for orientation and training on the facility, while others were silent on the issue. As a result, there was no assurance that contract staff received adequate training to recognize and prevent abuse, neglect, or exploitation, leading to a deficiency in protecting the health, welfare, and rights of residents.

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