Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide required behavioral health training to eight out of ten staff members, as evidenced by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, "In-Service Training, All Staff," mandates that all personnel receive education and training related to resident care, including behavioral health. However, the training records revealed that Nurse Aides E11, E12, E13, and E15, Registered Nurses E16 and E19, Medical Records Employee E17, and Therapy Employee E18 did not have documented behavioral health training within the specified time frames after their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of behavioral health training for these staff members. This deficiency is a violation of the facility's policy and the regulatory requirements 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
Immediate Intervention: All nursing staff were provided with Behavior Health training on the electronic platform. How to identify residents who can be affected: All employees can be affected. Prevention of further occurrence: Nurse educator reviewed the training platform and discovered that 0949 was not uploaded to the training platform. Behavior Health Training has since been uploaded, and employees have been given 30 days to complete training. By June 6, 2025, all employees will have 0949 training completed. Corrective action required: Nurse educator to review all staff training compliance monthly and report to DON delinquent staff. DON will pursue corrective action and discipline for employees who are non-compliant. QA Program: Nurse educator will report on staff compliance of staff education monthly at QAPI.