Failure to Complete Required QAPI Training
Summary
The facility failed to ensure QAPI training was completed for 19 of 24 employees reviewed for training requirements. Record review showed that the Administrator, DON, Activity Director, multiple LVNs, CNAs, RNs, the ADON, and other direct care and support staff did not have evidence of annual QAPI training in the prior 12 months. Record review also showed that the Dietary Manager, Social Worker, and Restorative Aide P did not complete QAPI training upon hire. Personnel records showed hire dates for the affected employees, including staff hired in 2021 through 2025, and the training logs provided by human resources did not show QAPI training completion as required. For the employees reviewed, the facility could not provide documentation that the required QAPI training had been completed either at hire or annually, depending on the employee’s role and hire date. A policy identifying required training topics and frequency of training was requested from HR and the Administrator but was not provided prior to exit. During interviews, HR stated the facility used a training packet for staff upon hire and annually, but that the packet did not include QAPI training. HR, the ADON, the DON, and the Administrator each stated they were responsible for ensuring staff completed required training, and each acknowledged they were unaware that QAPI training was not included in the packet. The Administrator stated he was ultimately responsible for ensuring staff received the required training, and the DON stated she supervised the ADON who was responsible for ensuring staff received training upon hire and annually.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to provide annual Effective Communication training for two nurse aides. Personnel file review showed the required in-service training was missing for both staff members, and HR confirmed the lapse during interview. Facility policy identified Effective Communication as mandatory training for direct care staff.
The facility failed to ensure mandatory effective communication training was provided to a sampled RN, LPN, and four CNAs. Training records showed none of the six employees had received this training, and the DON and regional director stated that effective communication was not included in the training program.
The facility failed to ensure agency staff completed required communication training. Record review showed no documentation that agency CNA P, CNA Q, and an LN had completed the training, and Administrative Staff B stated the facility expected the agency to have already provided the required in-services before scheduling staff. The facility also could not provide a policy on required staff in-services.
The facility failed to provide Communication training to five of five direct care staff members reviewed, including an LPN, three NAs, and an RN. The NHA stated that education is tracked by calendar year and that no education records could be found for the identified staff for the prior year. The HR Director confirmed the lack of Communication training records for these staff members.
The facility did not ensure that 5 of 5 CNAs reviewed received required communication training. The CNAs had all worked at the facility for more than 1 year, but the facility could not provide evidence of the training. The HR Director said HR handled onboarding only and did not track annual training, while the NHA and DOO confirmed there was no evidence of the training and no organized system for employee training records.
Facility staff did not maintain an effective training program for RNs, LPNs, CNAs, and other employees, with no documented education on behavioral health care or communication, including communication with a Spanish-speaking resident. Staff reported they had not been trained to communicate with this resident and instead relied on the family and a Spanish-speaking ADON to translate. The Staff Development Coordinator confirmed the absence of training records and there were no communication tools or established communication process in the resident’s room. Facility leadership was informed that required staff training, including communication training, was not effectively maintained or documented.
Missing Annual Effective Communication Training for Nurse Aides
Penalty
Summary
The facility failed to provide annual training on Effective Communication for two of three nurse aide staff members, Employees E2 and E3. Facility policy stated that compliance with the facility’s standards, policies, procedures, and training program was a condition of employment, and the Training Requirements- Communication Training policy identified effective communication as mandatory training for direct care staff. Review of Employee E2’s personnel record showed a hire date of 3/12/24, but the file did not contain annual in-service training on Effective Communication for the period 3/12/25 through 3/12/26. Review of Employee E3’s personnel record showed a hire date of 4/15/24, but the file did not contain annual in-service training on Effective Communication for the period 4/5/25 through 4/5/26. During an interview on 4/19/26 at 1:50 p.m., Human Resource Employee E9 confirmed that the facility failed to provide annual training on Effective Communication for these two staff members.
Failure to Provide Mandatory Effective Communication Training
Penalty
Summary
The facility failed to ensure that all staff received mandatory training on effective communication for six of six employees reviewed, including one RN, one LPN, and four CNAs. During the extended survey review, the facility administrator was asked to provide training records for the sampled employees, and the records showed that none of the six had received training on effective communication. When the findings were reviewed with the administrator, DON, and regional director of operations, the DON and regional director stated that they identify training needs based on policies and sometimes by talking to people or employees, and that effective communication was not included as a topic in their training program.
Failure to Verify Required Communication Training for Agency Staff
Penalty
Summary
The facility failed to ensure agency staff received the required communication training. During record review on 05/14/26, documentation could not be provided showing that agency CNA P, CNA Q, and LN K had completed the facility's communication training. During an interview later that day, Administrative Staff B stated she was responsible for scheduling agency staff and that the facility expected the agency to have already provided the required training and in-services to its staff before they were scheduled at the facility. The facility was also unable to provide a policy related to staff required in-services when requested.
Failure to Provide Communication Training to Direct Care Staff
Penalty
Summary
The facility failed to provide Communication training to five of five direct care staff members reviewed, including an LPN, three NAs, and an RN. During interviews, the NHA stated that staff education is tracked by calendar year from January through December, and that the State Agency requested employee education records for the identified staff. The NHA later stated that the facility was unable to find any education records for those employees for the year 2025. The HR Director then confirmed that the facility failed to provide Communication training to five of five direct care facility staff. The deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of Licensee and 28 Pa. Code 201.20(a) Staff Development.
Missing Required Communication Training for Direct Care Staff
Penalty
Summary
The facility did not ensure that 5 of 5 direct care staff reviewed received the required communication training. The staff reviewed were CNAs TT, UU, VV, WW, and XX, all of whom had worked at the facility for longer than 1 year. The facility policy titled Training Requirements, last revised 1/1/25, states that training content includes effective communication for direct care staff and that documentation of required training is to be forwarded to HR for placement in the personnel file. On 5/4/26, the surveyor reviewed the records for the 5 CNAs and found the facility was unable to provide evidence that they had received the required communication training. On 5/5/26, the HR Director stated that HR handled new-employee onboarding but did not track annual trainings after hire, and that annual training should be kept track of by nursing. The HR Director also stated there was currently no Nurse Educator or Staff Development Coordinator. The NHA and Director of Operations confirmed the facility had no evidence of communication training being provided and stated training records were in boxes kept by the previous DON, with no organized system for employee trainings.
Failure to Maintain Effective Staff Training on Behavioral Health and Communication
Penalty
Summary
Facility staff failed to develop, implement, and maintain an effective training program for all staff, specifically lacking required education on behavioral health care and communication. During an extended survey conducted after substandard quality of care was identified, surveyors interviewed the Staff Development Coordinator, who stated she had no evidence that behavioral health training had been provided to all staff and acknowledged that some staff only received computer-based training. Review of educational records for five nursing staff members (two RNs, one LPN, and two CNAs) showed no documentation of training on behavioral health care. Staff interviews further revealed that these employees had not received training on communication with a Spanish-speaking resident. Staff reported that they relied on the resident’s family to translate and on the Assistant DON, who spoke Spanish, rather than on any formal training or structured communication process. The Staff Development Coordinator confirmed there was no documentation of any employees receiving training on communication with a Spanish-speaking resident, and surveyors observed that there were no communication tools in the Spanish-speaking resident’s room and no developed or implemented process for communicating with that resident. Facility leadership, including the Administrator, Assistant Administrator, Regional Nurse Consultant, and DON, were informed that required training, including communication training, was not being effectively maintained or documented.
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