Operating organizations for skilled nursing/long-term care facilities must incorporate compliance and ethics training into their overall compliance program, communicating standards, policies, and procedures to all staff through a formal training program or equivalent method. Organizations that operate five or more facilities must conduct this training annually. Facilities must maintain a tracking system to document staff participation in required compliance and ethics training.
View official sourceF946 (Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.95(f) Compliance and ethics. The operating organization for each facility must include as part of its compliance and ethics program, as set forth at §483.85— §483.95(f)(1) An effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program. §483.95(f)(2) Annual training if the operating organization operates five or more facilities. DEFINITION: For the purpose of this guidance, the term “Staff” includes all new and existing staff (direct and indirect care functions); individuals providing services under a contractual arrangement; and volunteers, consistent with the volunteers’ expected roles (see requirements in §483.95). GUIDANCE §483.95(f) The operating organization (the individual or entity that operates a facility) must provide a training program or another practical manner to effectively communicate the standards, policies, and procedures of the compliance and ethics program to its entire staff. For the operating organizations that operate five or more facilities, annual training for staff on the compliance and ethic program must be conducted. All training should support current scope and standards of practice through curricula which detail learning objectives, performance standards, and evaluation criteria. There should be a process in place to track staff participation in the required trainings. PROBES §483.95(f) • Does the facility provide training or effectively communicate, in some manner, the facility’s standards, policies and procedures of the compliance and ethics program? • Does the facility have a system in place to track staff attendance at required trainings? • For organizations with five or more facilities, determine if annual compliance and ethics training is provided.