A training checklist for every personnel file

Behavioral health organizations must provide a variety of role-specific training based on the types of services the organization provides and the type of employees who provide those services.  

Depending on the clinic, facility, or practice, clinicians may need specific compliance training in elopement prevention and reporting procedures, new required screening tools,  new quality measure reporting, and more.

Billers may need training in new types of audits, while administrative staff may need training in confidential records handling processes or the collection of consent forms. 

There are as many different types of role-specific compliance training as there are jobs. The Office of Inspector General (OIG) expects your organization to provide specific training no less than annually and update your personnel files accordingly.  (See my detailed Compliance Report on OIG expectations for staff training. ) 

But the training doesn’t end there. In addition to role-specific training, every employee should receive training in the organization’s general compliance program and compliance risks, as well as many other areas.

While the following list is not all-inclusive, it offers a basic guide for the types of training and documentation specifics that should be included in each employee’s personnel file.

A Training Checklist for Personnel Files

  1. Each employee needs a Written Education Plan, which should:
    • Include a requirement that licensed personnel must complete all education and training mandated by the licensing board that governs their license.
    • State the Continuing Education requirements for the job classification.
    • Define the required number of hours for in-service or continuing education.
    • Include measurements for success to be used as part of training follow-up. How will the employee be evaluated? What constitutes success?
    • Define frequencies. How often will evaluations take place?
    • Reflect content used in the training. Show what the employee learned.
  2. All employees should understand the basics of the organization’s Compliance Program. Compliance training should describe the organization’s commitment to comply with all Federal, State, and local standards.

    Make certain employees know:

    • All applicable fraud and abuse laws, such as the Federal False Claims Act and the Anti-Kickback Statute, are included.
    • The identity and role of the compliance officer
    • The procedures they (and contractors) should use to ask compliance questions or voice compliance concerns.
    • The role of the Compliance Committee
    • There is no retaliation allowed for disclosing or raising compliance concerns
    • The means through which the organization enforces written policies and procedures equitably and impartially
    • Ensure the requirements outlined in each employee’s Written Education Plan align with your organization’s policies and procedures. Discrepancies will result in survey citations.

    • Targeted training sessions should address Federal health care program regulations applicable to the organization’s business.

How SimiTree can help

With so much training required, your behavioral health organization may need help to cover all the bases. New comprehensive compliance guidance released by the OIG in late 2023 states that an entity may choose to develop its own training materials, purchase training materials from a third-party vendor, or contract with an external party to develop the training materials.

SimiTree works with clients to develop and provide individualized training for full compliance. Our clinical, operational, and compliance experts fully understand the relationship between quality and compliance and help behavioral health providers mitigate risk while optimizing performance.

We can help your organization develop a dynamic compliance program fully compliant with new OIG guidance, provide all needed staff training to meet and adhere to regulations, and conduct a full compliance risk assessment to identify vulnerabilities for targeted training.

Reach out to us today to learn how we can help your organization.

NEXT WEEK: Is your DCO agreement up to standards?

In 2024, it's more important than ever to stay abreast of compliance issues, and I don’t want you to miss any of my Weekly Compliance Reports.

Be sure to add your name to the subscription list here.

Why not invite the compliance officers you know to sign up as well?


J’non Griffin serves as Senior Vice President/Principal for the Compliance as well as Coding divisions at SimiTree. Her healthcare career spans three decades of clinical and leadership experience, and she has a track record of helping many provider types implement effective compliance programs. She is a certified ACHC and CHAP consultant and holds additional certifications in diagnosis coding and other healthcare specialties. As an AHIMA ambassador, she was instrumental in the implementation of ICD-10.