Lack of EBP Training and Policy in Facility
Summary
The facility failed to maintain an effective infection control training program for all 94 staff members by not developing a written policy and training regarding Enhanced Barrier Precautions (EBP). EBP involves the use of gowns and gloves during high-contact resident care activities to reduce the spread of infections. During an observation, it was noted that there was no personal protective equipment (PPE) cart or EBP signage by the door of a resident's room who had unstageable pressure injuries. Interviews with various staff members, including the Interim Infection Preventionist, Registered Nurse, Psychiatric Technician, RN Shift Lead, Supervising RN, and Nursing Coordinator, revealed a lack of awareness and training on EBP. The staff admitted to not using gowns during wound care and were unaware of the EBP guidelines. The facility was unable to provide a policy for EBP upon review, and staff interviews confirmed that no training had been conducted. The Interim Infection Preventionist and other staff members acknowledged that they were not up to date with EBP and that the facility's policy did not address it. The lack of training and policy on EBP had the potential to negatively affect the facility's ability to maintain a safe environment and prevent the spread of infectious diseases among the 54 residents in the facility.
Penalty
Resources
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The facility did not provide required infection control training to multiple direct care staff members, despite a policy stating that all employees must complete mandatory education within set time frames. Review of annual education records showed that two NAs and two RNs lacked documented infection control training, and the HR director confirmed that education is organized by calendar year. The NHA acknowledged that the facility failed to ensure these direct care staff received infection control education as required by state regulations.
A dietary aide was found to have no credible evidence of completing mandatory infection control training, as required by facility policy. The DON and Regional Director of Clinical Services confirmed that all employees should have this training, but documentation was lacking and no policy was provided when requested.
Four staff members, including three nurse aides and an LPN, did not receive mandatory annual infection control training as required by facility policy and regulations. Personnel file reviews and staff interviews confirmed the absence of this training within the specified timeframes.
A review of staff files revealed that not all employees received required infection control training, with one staff member lacking documentation of completion. The HR Director and Corporate Nurse were unable to produce or verify records of this training due to unsystematic maintenance of education records.
Two direct care staff members, a nursing assistant and an LPN, did not receive required infection control training as mandated by facility policy and regulatory standards. Personnel file reviews and administrative interviews confirmed the absence of documented infection control education for these staff, despite annual training requirements.
The facility failed to ensure that clinical staff received and had documented mandatory infection control education as required by its own policies and facility assessment. A RN and an LPN had personnel files showing signed job descriptions and general orientation acknowledgments, but no clear evidence of infection control training being assigned or completed, and the training system confirmed no such training for them. A later annual education roster listed these staff with handwritten check marks but did not specify when training was completed. Additional staff interviews revealed that a CNA had not received infection control training despite on-the-job orientation, while an LPN described general in-services and CBTs. The DON stated that infection control education is required at hire and annually, consistent with written policies, but the documented training for these staff did not meet those requirements.
Failure to Provide Required Infection Control Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required infection control training to most of the direct care staff reviewed as part of its infection prevention and control program. 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 infection control training. In a subsequent interview, the Nursing Home Administrator confirmed that the facility failed to provide infection control training to these direct care staff members, in violation of 28 Pa. Code 201.14(a) and 201.20(c). No residents or specific patient conditions were mentioned in the report, and the deficiency centered solely on the lack of mandatory infection control education for direct care personnel as required by facility policy and state regulations.
Failure to Provide Required Infection Control Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide required infection control training for a dietary aide, as evidenced by a review of six employee records during an extended survey. The dietary aide in question was hired on 8/26/25, but there was no credible evidence that this employee had completed the mandatory infection control training. The Director of Nursing (DON) acknowledged that her focus was primarily on clinical staff training and could not provide documentation that the dietary aide had received infection control training. A document presented as evidence of training was dated prior to the employee's hire date and was therefore not considered credible. Further review of the dietary aide's training transcript did not reveal any infection control training since employment at the facility. The Regional Director of Clinical Services confirmed that all employees were expected to complete infection control training. Additionally, when asked, the DON was unable to provide a copy of the facility's policy on staff training. No further information or documentation was provided by facility leadership to address the concern regarding the lack of infection control training for the dietary aide.
Failure to Provide Required Infection Control Training to Staff
Penalty
Summary
The facility failed to provide mandatory infection control training to four out of seven reviewed staff members, including three nurse aides and one LPN. According to the facility's own policy, all staff, including those under contractual arrangements and volunteers, are required to complete infection prevention and control training prior to independently providing services, annually, and as necessary based on the facility assessment. Personnel file reviews revealed that these four staff members did not have documentation of infection control training within the required annual period following their respective hire dates. This deficiency was confirmed during an interview with a Human Resources employee, who acknowledged that the required infection control training had not been provided to the identified staff members. The lack of training was found to be inconsistent with both federal and state regulations, as well as the facility's internal policies regarding staff development and infection prevention.
Plan Of Correction
Employee's 5, 6, 8, and 9 will receive the Infection Control training in January 2026. All employees will receive an annual Infection Control training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Infection Control training. Human resource Director or designee will audit the training to assure all staff have been educated on Infection Control training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Ensure Mandatory Infection Control Training for All Staff
Penalty
Summary
Facility staff failed to ensure that all employees received mandatory training for the Infection Control program, as required by the facility's infection prevention and control policies. During a review of six staff files, it was found that one staff member did not have documentation indicating completion of the required infection control training. The Human Resources Director was unable to provide evidence that the training was completed for this staff member, despite multiple attempts to locate the records. Additionally, the Corporate Nurse confirmed that education records were not systematically maintained, making it impossible to determine if or when the training was provided.
Failure to Provide Infection Control Training to Direct Care Staff
Penalty
Summary
The facility failed to provide mandatory infection control training to two of five direct care staff reviewed, as required by its infection prevention and control program. Review of the job descriptions for both nursing assistants and LPNs indicated that staff are required to complete all assigned training, including that mandated by law or regulation. Personnel file reviews revealed that a nursing assistant hired in 2000 and an LPN hired in 2020 did not have any documented education or training regarding infection control. Interviews with the Human Resources Director and the Nursing Home Administrator confirmed that these staff members had not completed the necessary infection control education, despite annual training requirements.
Failure to Provide and Document Required Infection Control Training for Clinical Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff received mandatory infection prevention and control education as required by its infection control program and staff development policies. A registered nurse hired in early August 2024 had a personnel file that included a signed job description and a general new employee orientation acknowledgment, but there was no documentation specifying what training topics were covered, and no evidence that infection control training had been completed. Review of the in-service training log and the facility’s electronic training system, confirmed by the HR representative, showed that infection control training was neither assigned nor completed for this nurse at the time of survey. A similar lack of documentation was found for an LPN hired in September 2016. The LPN’s personnel file contained a signed job description requiring participation in all required trainings, but there was no evidence of completed infection control training. The HR representative and surveyor verified in the training system that infection control training had not been assigned or completed for this LPN. After survey exit, the facility submitted an email with an attached “Clinical Staff Annual Education” roster listing both the RN and LPN with handwritten check marks indicating training completion, but the document did not clearly indicate when the training occurred or provide specific dates of completion. Additional staff interviews supported the finding that infection control education was not consistently provided or documented. An LPN reported that staff receive monthly in-services and annual computer-based training and stated that training on infection control is important so staff do not spread infections. A CNA, described as relatively new, reported receiving on-the-job training but no infection control training, and was told there would be online training to complete within two months. The DON stated that staff are expected to complete onboarding orientation and periodic education throughout the year, and emphasized that infection control training is important to prevent knowledge deficits that could delay responses and impact care. Facility policies and the facility assessment specified that infection control education is mandatory on hire and annually, and that infection control is a required competency to be started during orientation and completed within the first weeks of hire and then annually, but the documented practices for the identified staff did not align with these requirements.
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