Failure to Implement Effective Behavioral Health Training Program
Summary
The facility failed to develop, implement, and maintain an effective training program for all staff, including behavioral health care and services training, as determined by staff need and the facility assessment. This deficiency affected two sampled employees hired within the last year. The facility census was 96. The facility did not provide a policy regarding behavioral health training, and the facility assessment had not been reviewed annually since 2023. Additionally, there was no documentation showing that the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee reviewed the facility assessment. The number of residents with intellectual and/or developmental disabilities was inaccurately reported, and the behavioral healthcare needs, including trauma and PTSD, were also inaccurately documented. The competencies required by the facility did not include essential areas such as catheter care, falls, communication, behavioral health, or meeting the needs of individuals with mental illness or intellectual/developmental disabilities. Review of the medical diagnoses of the 96 residents present during the on-site survey revealed a significant number of residents with various mental health conditions, including schizophrenia, bipolar disorder, anxiety, depression, schizoaffective disorder, history of suicide attempts or suicidal ideations, personality disorder, PTSD, and psychosis. Despite this, there was no documentation of behavioral health training for two Certified Nurse Aides (CNAs) hired within the last year. During interviews, the Assistant Director of Nursing (ADON) admitted that they could not find the in-services from the previous Directors of Nursing (DON) and that the specific training for behavioral residents was unknown. The Administrator acknowledged the need for behavioral health training in the facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not provide required Behavioral Health training to multiple direct care staff members, including NAs and RNs, despite a policy stating that all employees must complete required education within set time frames. The HR Director reported that staff education is organized by calendar year, but review of education records showed that four direct care staff lacked any documented Behavioral Health training. The NHA confirmed that Behavioral Health training had not been provided as required by the facility assessment and state staff development regulations.
The facility did not ensure that all nursing staff attended required behavioral health in-service training, as only a portion of the staff participated despite the training being mandatory. This failure was identified through a review of training records and confirmed by facility leadership, in violation of facility policy and regulatory expectations for staff competency in behavioral health care.
The facility did not provide required behavioral health training to a RN, three NAs, and an LPN, as evidenced by missing documentation in their personnel files and confirmed by HR. This failure was identified through review of training records and staff files, in violation of regulatory requirements for staff development.
Staff did not receive required behavioral health training to manage a resident with psychiatric and neurocognitive diagnoses who exhibited disruptive and aggressive behaviors, resulting in an incident where the resident spat at a CNA and alleged physical abuse. The facility could not provide documentation that the CNA had completed necessary mental health or behavioral health in-service training, despite facility policies requiring such training for staff caring for residents with mental health needs.
Three direct care staff, including two nurse aides and an LPN, did not receive required behavioral health training as indicated by their job descriptions and personnel files. Facility documents and staff interviews confirmed the absence of this training, which is mandated by state regulations and the facility's own assessment.
The facility did not provide required behavioral health training to two nurse aides and an LPN, as shown by missing documentation in their training records and confirmed by the Nursing Educator.
Failure to Provide Required Behavioral Health Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Behavioral Health training to direct care staff as identified through policy review, education records, and staff interviews. The facility’s Continuing Education policy dated 9/22/25 stated that all levels of employees are expected to complete required trainings within designated time frames, and the Human Resources Director reported that education is conducted on a calendar-year basis from January through December. However, review of 2025 facility education documents showed that a nurse aide (Employee E1), a registered nurse (Employee E3), another nurse aide (Employee E4), and another registered nurse (Employee E6) had no documented Behavioral Health training. During an interview, the Nursing Home Administrator confirmed that the facility did not provide Behavioral Health training to these direct care staff members, in violation of state requirements and the facility assessment. No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on the lack of Behavioral Health training for the identified staff members, contrary to 28 Pa. Code: 201.14(a) Responsibility of Licensee and 28 Pa. Code: 201.20(c) Staff Development.
Failure to Provide Mandatory Behavioral Health Training to All Nursing Staff
Penalty
Summary
The facility failed to provide mandatory in-service behavioral health training to all nursing staff as required by its own policies and as scheduled on the in-service calendar. A review of the training sign-in sheets for the scheduled behavioral health in-service revealed that only 36 out of 142 nursing staff attended, despite the training being mandatory for all licensed nurses and certified nursing assistants. The Director of Staff Development confirmed that not all staff attended the training, and the Director of Nursing reiterated that attendance was required for all nursing staff. The facility's policies specify that all staff must participate in regular in-service education, including behavioral health topics such as recognizing psychosocial distress, implementing care plan interventions, and following protocols for mental health conditions. The facility assessment indicated that the resident population includes individuals with psychiatric and mood disorders, and that staff are expected to be trained to care for residents with dementia and other mental health issues. The failure to ensure full staff participation in behavioral health training resulted in noncompliance with facility policy and regulatory requirements.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training to five out of seven reviewed staff members, including a registered nurse, three nurse aides, and a licensed practical nurse. According to the facility's own policy, all staff are to receive training in behavioral health annually and as necessary based on the facility assessment. Personnel files for these staff members showed no evidence of behavioral health training within the required timeframes following their respective hire dates. This deficiency was confirmed during an interview with a human resources employee, who acknowledged that the required behavioral health training had not been provided to the identified staff members. The lack of training was found through a review of facility policies, training records, and staff files, and was cited as a violation of both federal and state regulations regarding staff development and the responsibility of the licensee.
Plan Of Correction
Employee's 3, 5, 6, 8, and 9 will receive the Behavioral Health training in January 2026. All employees will receive an annual Behavioral Health training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Behavioral Health training. Human resource Director or designee will audit the training to ensure all staff have been educated on Behavioral Health training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Provide Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure that staff received behavioral health training as required, specifically in managing residents with maladaptive behaviors such as being disruptive, cursing, and spitting at staff. This deficiency was identified during the review of an incident involving a resident with diagnoses including bipolar disorder, post-traumatic stress disorder, and frontotemporal neurocognitive disorder. The resident, who had a history of making false statements and being easily frustrated with staff, was involved in an altercation where they took a piece of cake intended for another resident, ate it, and then spat it at a CNA after being confronted. The CNA involved in the incident attempted to retrieve the cake and placed her hand in front of the resident's mouth to prevent being spat on, which led to the resident alleging that the CNA hit them. The CNA later acknowledged that her response was inappropriate and that she should have walked away instead. The facility's documentation did not provide evidence that the CNA had received specific behavioral health or mental health training, nor was there documentation confirming completion of the required annual in-service training on these topics. The facility's assessment indicated that services were provided for residents with mental health and behavioral needs, and that training and competency checks were to be conducted upon hire, monthly, and annually, including dementia management and care of cognitively impaired residents. However, the lack of documented evidence of behavioral health training for the CNA contributed to the deficient practice, as staff were not adequately prepared to cope effectively with residents exhibiting challenging behaviors.
Failure to Provide Behavioral Health Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required behavioral health training to three of five direct care staff reviewed. Review of job descriptions for nursing assistants and LPNs indicated that staff are expected to complete all training and education as assigned and as required by law and regulations. Personnel files and continuing education transcripts for two nurse aides and one LPN showed no evidence of behavioral health education. Interviews with the Human Resources Director confirmed that annual training is required for staff, and the Nursing Home Administrator confirmed that the identified staff members had not completed the necessary behavioral health education. This deficiency was identified through review of facility documents, job descriptions, personnel files, and staff interviews. The lack of behavioral health training was found to be inconsistent with the requirements outlined in the facility assessment and state regulations. No information was provided regarding the impact on residents or specific incidents resulting from this deficiency.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training to three out of ten staff members, specifically two nurse aides and one LPN, as evidenced by a review of facility education documents and training records. The records for these staff members did not include documentation of behavioral training as mandated by facility policy and regulatory requirements. This deficiency was confirmed during an interview with the Nursing Educator, who acknowledged that the behavioral training had not been provided to the identified staff members. No information regarding residents, their medical history, or their condition at the time of the deficiency was included in the report.
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