Failure to Provide Required Annual In-Service Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff, including Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs), received the required 12 hours of annual in-service education and demonstrated competency as mandated by facility policy. Record review revealed that the credentialing files for four staff members lacked evidence of completion of the required yearly training. The missing in-service education included essential topics such as infection control, HIPAA, resident rights, abuse prevention, compliance, emergency preparedness, and behavioral health, among others. During interviews, administrative staff confirmed that the responsibility for tracking and ensuring completion of nurse aide in-services had previously been assigned to the facility scheduler. However, it was discovered that CNAs and CMAs had not completed the necessary annual education hours. The director of nursing (DON) was subsequently identified as the new responsible party for ensuring compliance with training requirements. The facility census at the time was 65 residents.