Failure to Develop and Implement Compliance and Ethics Program
Summary
The facility failed to develop and implement a compliance and ethics program, as well as to provide staff with compliance and ethics training. Interviews with the Administrator and two Regional RNs revealed that there was no compliance and ethics program or policy in place, and that such training was not included in new hire orientation or annual training. Although a Code of Conduct policy existed, it was not communicated to all facility staff and did not include essential components such as identification of a compliance officer or committee, procedures for reporting ethical concerns, secure and confidential reporting mechanisms, internal monitoring and auditing, or processes for response and corrective action. The Director of Nursing Services was unavailable for interview, and the requested compliance and ethics policy was not provided.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Surveyors found that the facility did not ensure all staff received required annual Compliance and Ethics training. Review of five randomly selected employee education files showed that one employee hired more than a year earlier had no documented Compliance and Ethics training during the review period. The administrator confirmed there was no evidence that this staff member had completed the mandatory annual training.
The facility did not provide required Compliance and Ethics training to multiple direct care staff, despite a policy stating all employees must complete mandatory education within set time frames. Review of education records showed that several NAs and RNs lacked any documented Compliance and Ethics training for the year, and leadership confirmed that this training had not been provided, resulting in noncompliance with state staff development and licensee responsibility regulations.
A dietary aide was found to have no credible evidence of having completed required compliance and ethics training after being hired. Documentation provided was either dated before employment or did not include the necessary training, and facility leadership could not produce a staff training policy or additional proof of compliance.
The facility did not provide required annual Compliance and Ethics training to several staff members, including an RN, multiple NAs, and an LPN, as confirmed by personnel file reviews and staff interviews. This failure was in direct violation of facility policy and regulatory requirements for staff development and compliance training.
Two direct care staff members, a nurse aide and an LPN, did not receive required compliance and ethics training as indicated by their job descriptions and confirmed by personnel file reviews and administrative interviews.
The facility did not provide Compliance and Ethics training to three nurse aides, as confirmed by a review of training records and staff interview. This failure was verified by the Nursing Educator and is not in accordance with required staff development regulations.
Failure to Provide Mandatory Annual Compliance and Ethics Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received mandatory annual Compliance and Ethics training, as evidenced by the education record of one employee. During a complaint survey, surveyors reviewed education records for five randomly selected employees for the period from January 2025 through February 2026. For Staff #20, who was hired on 7/31/24, there was no documentation showing completion of Compliance and Ethics training during that review period. In an interview on 2/9/26 at 2:13 PM, the Administrator confirmed there was no evidence that this staff member had received the required annual Compliance and Ethics training. This deficiency was identified for 1 of 5 employees whose records were reviewed for compliance with the facility’s mandatory Compliance and Ethics education requirements.
Failure to Provide Compliance and Ethics Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required Compliance and Ethics training to most of the direct care staff reviewed, contrary to its own Continuing Education policy dated 9/22/25, which states that all levels of employees are expected to complete required trainings within designated time frames. The Human Resources Director reported that education is conducted on a calendar-year basis from January through December, yet 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 Compliance and Ethics training. During a subsequent interview, the Nursing Home Administrator confirmed that the facility did not provide Compliance and Ethics training to these direct care staff, resulting in noncompliance with 28 Pa. Code 201.14(a) and 201.20(c). No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the lack of required Compliance and Ethics education for direct care personnel as identified through policy review, education record review, and staff interviews.
Failure to Provide Compliance and Ethics Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide the required compliance and ethics training for one dietary aide, as identified during a review of six employee records. The dietary aide in question was hired on 8/26/25, but there was no credible evidence that this individual had completed the necessary compliance and ethics training. The only documentation produced was a Skills Competency Validation Record dated prior to the employee's hire date, and a transcript from the employee's phone app showed no record of the required training since employment. The Regional Director of Clinical Services confirmed that all employees were expected to complete compliance and ethics training. During interviews, the DON stated that her focus was primarily on clinical staff training and that all new employees should receive training on resident rights, abuse, and other basics during orientation. When specifically asked about dietary staff, the DON agreed that they should receive training on infection control, abuse, kitchen safety, quality assurance, compliance, ethics, and resident rights before starting their duties. However, no staff training policy was provided upon request, and no additional information was presented by facility leadership to demonstrate compliance with training requirements.
Failure to Provide Annual Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide required Compliance and Ethics training to five out of seven reviewed staff members, including a registered nurse, three nurse aides, and a licensed practical nurse. Review of personnel files showed that these employees did not have documentation of annual Compliance and Ethics training within the required timeframes, despite the facility's policy mandating such training for all staff, contractors, and volunteers. The policy also specifies that training must be completed prior to staff independently providing services and must be conducted annually and as necessary based on the facility assessment. During an interview, the Human Resources employee confirmed that the facility did not provide the required Compliance and Ethics training to these staff members. The deficiency was identified through review of facility policies, personnel files, and staff interviews, and it was determined that the facility did not meet the federal and state requirements for staff development and compliance training.
Plan Of Correction
Employee's 3, 5, 6, and 8 will receive the Compliance and Ethics training in January 2026. All employees will receive an annual Compliance and Ethics training during a set month of the year. Human Resource Director will educate all Department Directors on the annual education requirements for Compliance and Ethics training. Human Resource Director or designee will audit the training to assure all staff have been educated on Compliance and Ethics training topic. Audit results will be turned into Quality Assurance meeting monthly.
Failure to Provide Compliance and Ethics Training to Direct Care Staff
Penalty
Summary
The facility failed to provide required compliance and ethics training to two of five direct care staff reviewed. Review of the job descriptions for both Nursing Assistants and Licensed Practical Nurses indicated that staff are required to complete all assigned training and education as mandated by law and regulation. Personnel file reviews revealed that a nurse aide hired in 2000 and an LPN hired in 2020 did not have any documented education regarding compliance and ethics. Interviews with the Human Resources Director and the Nursing Home Administrator confirmed that these staff members had not completed the necessary compliance and ethics education, as required by facility policy and state regulations.
Failure to Provide Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide required Compliance and Ethics training to three out of ten nurse aide staff members, as evidenced by a review of facility education documents and training records. Specifically, the records for these three nurse aides did not include documentation of education on Compliance and Ethics, which is mandated. This deficiency was confirmed during an interview with the Nursing Educator, who acknowledged that the training had not been provided to these staff members. The findings reference specific state regulations regarding the responsibility of the licensee, management, and staff development.
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