CMS SOM App. PP, Tag F940

A facility must develop, implement, and maintain an effective training program for

all new and existing staff; individuals providing services under a contractual

arrangement; and volunteers, consistent with their expected roles. A facility must

determine the amount and types of training necessary based on a facility assessment

as specified at § 483.71. Training topics must include but are not limited to—

INTENT

Facilities are required to develop, implement, and maintain an effective training program

for all staff. Appropriately trained staff can improve resident safety, create a more

person-centered environment, and reduce the number of adverse events or other resident

complications.

CMS recognizes that training needs are likely to change over time. Therefore, it is

necessary for facilities to have the flexibility to determine training needs based on its

facility assessment. Competencies and skill sets for all new and existing staff,

individuals providing services under a contractual arrangement, and volunteers must be

consistent with their expected roles. All facility staff needs to be trained to be able to

interact in a manner that enhances the resident’s quality of life and quality of care and

that they can demonstrate competency in the topic areas of the training program. The

facility is also expected to keep a record of these trainings. Training requirements should

be met prior to staff and volunteers independently providing services to residents,

annually, and as necessary based on the facility assessment. See §483.71(a) (2)(iv).

CMS does not propose a specific training mechanism to meet the Training Requirements

regulation, and the regulation does not specify that a member of the facility must conduct

the training activities. Facilities have the flexibility to work with outside entities to

provide facilitated training, computer-based training, self-directed learning, mentoring

and/or coaching. CMS encourages facilities to leverage community resources to assist

with developing training programs, identifying qualified instructors, identifying training

materials, and implementing facility training programs.

Based upon the outcome of a facility assessment, suggestions for additional training

topics may include, but are not limited to, advance care planning, cultural competence,

end-of-life care, geriatrics and gerontology (i.e., understanding of how human beings

change as they grow older), substance abuse, working with young and middle-aged

adults, grief and loss, interdisciplinary collaboration, person centered care, specialized

rehabilitative therapy, trauma informed care, intellectual disability, mental disorder and

quality of life and care.

There are various free online training tools and resources that facilities can use to assist

them in complying with this requirement. For example, the Agency for Healthcare

Research and Quality (AHRQ) released a set of training modules to help educate LTC

facility staff on key patient safety concepts to improve the safety of LTC facility

residents. (See

http://www.ahrq.gov/professionals/systems/long-term-care/resources/facilities/ptsafety/).

Long Term Care Ombudsman can provide in-service trainings to facility staff on a

variety of topics. In addition to the web based materials, instructor and student

handbooks can be sent to facilities at no additional cost.

For the purposes of this training requirement, staff includes all facility staff, (direct and

indirect care functions), contracted staff, and volunteers (training topics as appropriate to

role).

NOTE: References to non-U. S. Department of Health and Human Services (HHS)

sources or sites on the internet are provided as a service and do not constitute or imply

endorsement of these organizations or their programs by CMS. CMS is not responsible

for the content of pages found at these sites. URL addresses were current as of the date of

this publication.

Surveyors need to consider the facilities compliance for all training requirements at

§483.95. F940 would be cited as a result of the facility’s failure to implement trainings

for multiple training topics included at §483.95.