Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training to five out of seven reviewed staff members, including a registered nurse, three nurse aides, and a licensed practical nurse. According to the facility's own policy, all staff are to receive training in behavioral health annually and as necessary based on the facility assessment. Personnel files for these staff members showed no evidence of behavioral health training within the required timeframes following their respective hire dates. This deficiency was confirmed during an interview with a human resources employee, who acknowledged that the required behavioral health training had not been provided to the identified staff members. The lack of training was found through a review of facility policies, training records, and staff files, and was cited as a violation of both federal and state regulations regarding staff development and the responsibility of the licensee.
Plan Of Correction
Employee's 3, 5, 6, 8, and 9 will receive the Behavioral Health training in January 2026. All employees will receive an annual Behavioral Health training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Behavioral Health training. Human resource Director or designee will audit the training to ensure all staff have been educated on Behavioral Health training topic. Audit results will be turned into Quality Assurance meeting monthly.