Failure to Provide Required Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to ensure that five randomly selected staff members, including four Certified Nursing Assistants (CNAs) and one Dietary Aide, received the required training on compliance and ethics. According to the facility's own policy, all staff are mandated to participate in initial orientation and annual in-service training, which must include compliance and ethics program standards, policies, and procedures. The surveyor's review of employee records revealed that there was no documentation verifying that these staff members had completed the required compliance and ethics training. During interviews, the Nursing Home Administrator (NHA) acknowledged the lack of documentation and stated that there was no further evidence of completed required trainings for the selected staff. The NHA also indicated that education is a problem within the facility and mentioned considering the designation of a training coordinator. The deficiency was identified as having the potential to affect all 39 residents in the facility, as staff training is essential for ensuring quality of care and compliance with facility policies.