Deficiency in Staff Communication Training
Penalty
Summary
The facility failed to provide mandatory training on effective communication for five out of nine staff members, as required by §483.95(a). The deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including training on effective communication for direct care staff. However, documentation revealed that Nurse Aide Employees E1, E3, and E4, Dietary Employee E7, and Licensed Practical Nurse Employee E8 did not receive the required training within the specified time frames. The Nursing Home Administrator confirmed during an interview that the facility did not provide the necessary training on effective communication for these staff members. The lack of training was in violation of the facility's policy and the regulatory requirements, as outlined in 28 Pa Code sections 201.14(a), 201.18(b)(1), and 201.20(a)(c), which pertain to the responsibility of the licensee, management, and staff development, respectively.
Plan Of Correction
No residents were affected by this deficiency. Residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.