Failure to Provide Required Behavioral Health Training to Staff
Penalty
Summary
The facility failed to ensure that all staff received the required behavioral health training as outlined in its own policy and procedure. During a review of employee records for eight randomly selected staff members, including nursing, housekeeping, and dietary personnel, the facility was unable to provide documentation verifying completion of behavioral health training for any of these individuals. The policy requires all staff, including new hires and existing personnel, to participate in initial orientation and annual in-service training on behavioral health, with documentation maintained by the staff development coordinator or designee. Interviews with the Nursing Home Administrator (NHA) confirmed that there was no further documentation available to verify that the required training had been completed for the selected staff. The NHA acknowledged the lack of documentation and indicated that education was a problem within the facility. This deficiency had the potential to affect all 39 residents in the facility, as staff may not have been adequately prepared to address behavioral health needs as required by facility policy and federal regulations.