Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective behavioral health training program for both new and existing staff, as required by its own facility assessment and policy. Specifically, a review of six Certified Nursing Assistants' (CNAs) education files revealed no evidence that behavioral health or trauma-informed care training had been provided since February. The facility's resident profile indicates that 35-65% of its population is admitted with psychiatric or mood conditions, necessitating specialized care and interventions. Despite this, staff files for CNAs hired between March and July showed no documentation of required behavioral health training. Interviews with the Interim Director of Nursing, Administrator, and Director of Nursing confirmed the absence of this training, attributing it to the departure of the previous Social Worker and a lapse in the facility's learning platform. Further review found that the facility's behavioral health services policy, which outlines the need for staff to recognize psychological distress, implement and monitor care plan interventions, and follow protocols for mental disorders and trauma, was not accessible due to a transition between policy portals. The policy statement provided lacked an initial or revision date, and there was no evidence that staff were qualified or competent in behavioral health and trauma-informed care as required. The deficiency was identified through record reviews, staff interviews, and examination of facility policies.