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F0607
D

Failure to Provide Annual Abuse Training to Contracted Staff

Carlisle, Pennsylvania Survey Completed on 01-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Thornwald Home was found to be non-compliant with federal and state regulations regarding the development and implementation of abuse and neglect policies. The facility failed to ensure that all staff, including contracted personnel, received the required annual training on abuse prevention and reporting. Specifically, a review of the training records revealed that a contracted Physician Assistant, referred to as Employee 2, did not receive the mandatory annual abuse training in 2024. This omission was confirmed during an interview with the Nursing Home Administrator and the Assistant Director of Nursing. The facility's policy, titled "Freedom from Abuse, Neglect, and Exploitation of Residents and Misappropriate of Resident Property," mandates that all employees, including consultants and volunteers, receive education on abuse prevention and reporting upon hire and annually thereafter. The policy also requires an annual acknowledgment from vendors and contractors. However, the facility could not provide documentation of such training or acknowledgment for Employee 2, indicating a failure to adhere to their own policy and regulatory requirements.

Plan Of Correction

1. No individual resident has been identified. E2 has received training and education on the facility's abuse policy which covers the seven components of abuse. 2. The Executive Director/designee will review training records to validate that contracted care providers including UPMC Post Acute Providers have evidence of Annual or New Hire Abuse training within the previous year. 3. UPMC Post Acute Providers will be re-educated by the Executive Director/designee on the facility's abuse policy. 4. Monthly audits will be conducted for 3 months by the Executive Director or designee on facility training records to validate contracted care providers and UPMC Post Acute providers have completed annual abuse training or new hire abuse training within the previous year. Results of audits will be reported to the facility Quality Assurance Performance Improvement (QAPI) committee for review and/or further recommendation.

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