Failure to Provide QAPI Training to Majority of Staff
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide required Quality Assurance and Performance Improvement (QAPI) training to the majority of sampled staff. Review of the facility’s Staff Development Program policy, last reviewed on 12/5/25, showed that the facility was to maintain an ongoing, coordinated education program for personnel, including training related to residents’ problems, needs, rights, and technology. However, review of facility documents and personnel in-service training records revealed that eleven of fifteen staff members lacked documented QAPI education as required by this program. The missing QAPI training affected multiple disciplines and hire dates. Several nurse aides (employees E5, E6, and E7) did not receive QAPI education upon hire or within the specified annual in-service periods. Two LPNs (employees E9 and E10) and one RN (employee E11) similarly lacked QAPI in-service education during their respective annual review periods. Therapy staff (employees E12 and E13), a dietary employee (E14), and an environmental services employee (E15) also had no documented QAPI training either upon hire or within the designated annual timeframes. During an interview on 2/13/26, the Nursing Home Administrator confirmed that the facility failed to provide QAPI training for eleven of the fifteen reviewed staff members, in violation of 28 Pa Code sections 201.14(a), 201.18(b)(1), and 201.20(a)(c).
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