Here's where you may be falling short in staff training and education.

Staff training is so important that it is listed as the No. 3 element on the Office of Inspector General’s list of Seven Fundamental Elements of Compliance—but many behavioral health providers fall short in this area.  

From inadequate policies to missing documentation in personnel files, there are plenty of places to get it wrong, even when an organization prioritizes staff training and education.
Training was one of the areas heavily emphasized in comprehensive new healthcare compliance guidelines issued by the OIG in November 2023.

Read the full General Compliance Program Guidance, known as the GCPG.

OIG expectations for staff training

Let’s take a closer look at some of the OIG expectations in the area of staff training and education:

  • A detailed training plan. An effective training plan lays out who will be trained on what and how often. Timelines and specificity are important parts of an effective plan. It should address all pertinent Federal and state standards and potential compliance risks. Specify the topics to be covered, the audience for each topic, and when training will take place.
  • A fluid training plan. The training plan should be reviewed and updated annually at a minimum. However, the best practice is to update more frequently as needs arise. Have any concerns been identified in audits and investigations? Be sure to revise the training plan as quickly as possible to address those concerns.
  • Training for all. Top-to-bottom training is expected. Governing board members, officers, employees, contractors, and medical staff—everyone—should receive training at least annually. 
  • Targeted training. Employees should receive targeted training for their specific roles and responsibilities. Address risks specific to the job. This includes board members and their compliance oversight responsibilities.
  • Accessible training. Training must be accessible to all staff, and if you have a culturally diverse staff, materials must be made available in all necessary languages.
  • Mandatory training. The OIG recommends that participation in required training become a condition of employment and a component of an annual performance evaluation.
  • Ongoing training. Don’t limit training to annual formal classroom sessions. The OIG wants to see compliance officers seek and develop opportunities to provide education on compliance topics and risks throughout the year. The Change Healthcare cyberattack, for example, offered a timely opportunity for a cybersecurity refresher.
  • Training formats. The OIG encourages training in many different formats, including live (in-person or via videoconference), computer-based training, podcasts, and pre-recorded videos.

That’s a lot of recommended training. Perhaps more importantly, it’s a lot of associated documentation. Documentation is an area where many behavioral health providers run into problems.

Training is a top behavioral health Survey citation

The Accreditation Commission for Health Care (ACHC) reports that lack of adequate personnel training is the single most common deficiency noted in its behavioral health accreditation surveys.

Behavioral health providers aren’t necessarily failing to train staff; they’re failing to do so adequately. Most of the time, this means there is an issue with documentation.

SimiTree compliance consultants routinely encounter documentation issues when working with behavioral health organizations on survey readiness.    

Common training documentation omissions

A handful of the most common omissions in behavioral health training documentation are:

  • No record of training in the personnel file. Training was provided, but the personnel file was never updated.
  • The content is not specified. What did the employee actually learn? Employees need written plans of education specifying training content for their job classification.
  • Training policy does not establish specific training and education requirements for specific roles. How many hours of training will be required per year for this role? How will the employee be evaluated? How often will evaluations take place? What is the measure of success?
  • The policy fails to specify that licensed personnel must complete all education and training mandated by the licensing board that governs their license.

How SimiTree can help

Need help with your behavioral health organization’s training?

The OIG guidance 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: A training checklist for every personnel file

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Have a compliance question?

SimiTree’s healthcare experts can help! Our team is made up of former auditors and surveyors from across healthcare settings who help behavioral health organizations achieve accreditation from AOs, understand regulatory and compliance demands, and meet quality goals. We have the know-how and the experience to help your organization mitigate risk. Contact us today with all your compliance needs.

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.