CMS SOM App. PP, Tag F946

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.