Failure to Provide Annual Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide required Compliance and Ethics training to five out of seven reviewed staff members, including a registered nurse, three nurse aides, and a licensed practical nurse. Review of personnel files showed that these employees did not have documentation of annual Compliance and Ethics training within the required timeframes, despite the facility's policy mandating such training for all staff, contractors, and volunteers. The policy also specifies that training must be completed prior to staff independently providing services and must be conducted annually and as necessary based on the facility assessment. During an interview, the Human Resources employee confirmed that the facility did not provide the required Compliance and Ethics training to these staff members. The deficiency was identified through review of facility policies, personnel files, and staff interviews, and it was determined that the facility did not meet the federal and state requirements for staff development and compliance training.
Plan Of Correction
Employee's 3, 5, 6, and 8 will receive the Compliance and Ethics training in January 2026. All employees will receive an annual Compliance and Ethics training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Compliance and Ethics training. Human Resource Director or designee will audit the training to assure all staff have been educated on Compliance and Ethics training topic. Audit results will be turned into Quality Assurance meeting monthly.