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F0940
E

Deficient Staff Training and Documentation for Resident Transportation

Helena, Montana Survey Completed on 08-06-2025

Penalty

Fine: $22,315
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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 ensure that new and existing staff were properly educated regarding the transportation of residents, that yearly evaluations were completed and documented, and that written job titles and duties were maintained in staff files. Interviews revealed that onboarding trainings, job titles, and job duties were expected to be in staff files, but clinical trainings were kept separately. Review of staff files showed missing or incomplete onboarding documentation, with some documents unsigned or undated. One staff member's file lacked yearly evaluations, job title, job duties, and a driver's license, and there was no evidence of education related to their specific job role. The facility's policy required documentation of necessary training and licensure for staff authorized to drive the facility van, but this documentation was not consistently present. Staff interviews indicated that some employees had not received transportation education prior to a recent incident involving a resident, and others could not recall when they last received such training. Some staff expressed confusion about the new transportation policy or were unaware of it altogether, particularly newer employees. The lack of consistent and documented training, evaluations, and clear job descriptions contributed to staff feeling unprepared and uncertain about their roles and responsibilities regarding resident transportation.

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