Failure to Provide Behavioral Health Training to Staff
Summary
The facility failed to provide required behavioral health training to seven out of nine staff members, as evidenced by a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on October 20, 2024, mandates an effective training program for all staff, including behavioral health training. However, documentation revealed that several employees, including nurse aides, environmental services, dietary staff, and a maintenance director, did not receive the necessary behavioral health in-service education within the specified timeframes after their hire dates. During an interview, the Nursing Home Administrator confirmed the lack of behavioral health training for these staff members. This deficiency was identified in the context of the facility's broader training requirements, which also include communication, resident rights, infection prevention, and other critical areas. The failure to provide behavioral health training was noted alongside a separate issue regarding infection prevention and control training, which was also not provided to six of the nine staff members.
Plan Of Correction
No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services, Administrator and Director of Nursing developed a facility Training Plan to include: - Effective communication for direct care staff. - Resident rights and facility responsibilities for caring of residents. - Elements and goals of the facility's QAPI program. - Written standards, policies, and procedures for the facility's infection prevention and control program. - Written standards, policies, and procedures for the facility's compliance and ethics program. - Behavioral health. - Dementia management and care of the cognitively impaired. - Abuse, neglect, and exploitation prevention. - Safety and emergency procedures. All staff will receive education in these areas, provided by the Administrator and Director of Nursing or designee. Completed training will be signed and dated by staff after receiving the training. Moving forward, staff will receive this training upon hire (during orientation) and annually. Human Resources Director will complete a weekly audit for 4 weeks on all new hires to ensure they have received the required trainings in the training plan and will complete a monthly audit that all staff have completed the assigned monthly trainings to ensure continued annual training. Audit results will be reviewed by the Risk Management/Quality Assurance Committee until such a time consistent substantial compliance has been achieved as determined by the committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not ensure that all CNAs, including agency CNAs, received required behavioral health training as outlined in its facility assessment, which called for dementia management, resident abuse prevention, and care of cognitively impaired residents with behaviors. Review of training records for two agency CNAs showed no behavioral health training over the prior year, and both CNAs reported they had not received such training from either the facility or their agency, despite one CNA confirming they provide care to all residents. The AIT and DON acknowledged that these CNAs had not received the required behavioral health training.
A facility failed to ensure 1 of 5 staff had initial and annual Alzheimer's and dementia training. NA-G's file showed a hire date but no completed training for key topics such as ADL assistance, problem solving with challenging behaviors, or communication skills. The DON could not locate the initial hiring documentation, and the facility's in-service policy required dementia management and behavioral health training before staff provided services, annually, and as needed based on the facility assessment.
Surveyors found that the facility failed to maintain an effective training program that included required behavioral health education for all staff. When training records for several RNs, an LPN, and CNAs were reviewed, there was no documentation of behavioral health training, and interviewed staff could not recall receiving such training, only noting that some education occurred in person or on the computer. The Staff Development Coordinator acknowledged having no evidence that employees had received behavioral health care training, and facility leadership was informed that required behavioral health training was not documented or effectively implemented.
Missing Annual Behavioral Health Training: A CNA assigned to the memory care unit did not have documented annual dementia/behavioral health training completed for the current year. HR confirmed the employee had been assigned the training but had not finished it, despite having direct contact with residents with dementia and Alzheimer’s disease. Facility policy and the facility assessment both required ongoing annual dementia care training for staff with resident contact.
Lack of Behavioral Health Training Program: The facility failed to provide an effective behavioral health care and services training program for staff across the review period. The facility assessment identified a resident population receiving psychiatric and psychological services and noted staff education was key to quality care, but the annual training modules showed no evidence of training on behavioral symptoms, non-pharmacological interventions, or appropriate responses to residents with psychiatric or psychological needs. The DON and NHA could not provide documentation of such training and confirmed the facility cared for residents with complex behavioral health needs.
Behavioral Health training was not documented for five staff members, including NAs, an RN, and an LPN. Facility policy required regular in-service training, but personnel files for all five employees lacked credible annual Behavioral Health training for the review period, and the NHA confirmed the lapse during interview.
Lack of Behavioral Health Training for Agency CNAs
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs), including agency CNAs, received behavioral health training as required by the facility’s own Facility Assessment Tool. The Facility Assessment Tool dated 3/26/26 specifies that required in‑service training for nurse aides must include dementia management, resident abuse prevention, and, for nurse aides providing services to individuals with cognitive impairments, training on the care of cognitively impaired residents with behaviors. Review of the Facility Daily Census Report dated 4/29/26 shows that 72 residents were residing in the facility at the time of the survey. Review of the employee and training records for two agency CNAs (V9 and V10) for the period 4/30/25 through 4/30/26 showed no documentation of behavioral health training. In interviews, one agency CNA (V9) stated that they had not received behavioral health training from either the facility or the hiring agency, and another agency CNA (V10) stated they had not received any training within the last year and confirmed they provide care to all residents in the facility. The Administrator‑In‑Training (V1) and the DON (V2) confirmed that these agency CNAs had not received behavioral health training from the facility or their agency.
Missing Required Alzheimer's and Dementia Training
Penalty
Summary
The facility failed to ensure 1 of 5 staff had initial and annual Alzheimer's and dementia training. Review of nursing assistant (NA)-G's employee file showed a hire date of 1/10/25, but her Alzheimer's Disease or Related Disorder Training record did not show completion of training on an explanation of Alzheimer's disease and related disorders, assistance with activities of daily living, problem solving with challenging behaviors, or communication skills. A follow-up email reply from the DON stated the facility was unable to locate NA-G's initial hiring documentation, and no additional information was provided by the end of the survey period regarding the expectation for completion of initial Alzheimer's training. The facility's undated In-Service Training policy required staff to participate in regular in-service education, including effective communication with residents and families, resident rights, preventing abuse, dementia management, and behavioral health, with training completed prior to providing services, annually, and as necessary based on the facility assessment.
Failure to Maintain Effective Behavioral Health Training Program for Staff
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and maintain an effective training program that included required behavioral health care and services education for all staff, as identified during a survey that resulted in a finding of Substandard Quality of Care and an extended survey. During the survey, the survey team requested training schedules and documentation from the Staff Development Coordinator, who reported she had no evidence that behavioral health training had been provided to all staff, stating only that some staff had received training on the computer. A list of employees, including RNs, LPNs, CNAs, and other disciplines, was requested for review. Review of the educational records for five sampled nursing staff members (two RNs, one LPN, and two CNAs) showed no documentation of behavioral health training. When these staff members were interviewed, they reported they could not remember receiving behavioral health training and stated that some trainings were done in person and some on the computer, without being able to identify behavioral health content. The Staff Development Coordinator confirmed she did not have documentation of any employees receiving behavioral health care training. During end-of-day debriefings, facility leadership, including the Administrator, Assistant Administrator, Regional Nurse Consultant, and Director of Nursing, were informed that the facility lacked an effective training program regarding required topics, including behavioral health, and that education/training documents were maintained by the Staff Development Coordinator.
Missing Annual Behavioral Health Training
Penalty
Summary
Behavioral health care training was not completed annually for 1 of 18 sampled employees, Employee #7, a CNA hired on 06/17/2019. The personnel record showed annual behavioral health care training completed on 04/11/2025, but there was no documented evidence that the training had been completed in 2026. During interview on 04/22/2026, the HR Director stated that dementia care training was required annually for all staff on or before the date of last completion and confirmed that Employee #7 had been assigned the 2026 behavioral health care training but had not yet completed it. The HR Director also confirmed that Employee #7 worked in the facility's memory care unit and had contact with residents diagnosed with dementia and Alzheimer's disease. The facility policy for staff training in Alzheimer and dementia care required all staff with direct contact with residents with dementia to complete continuing education related to dementia every year after the first year of employment, and the facility assessment stated that staff would receive ongoing annual training in dementia care.
Lack of Behavioral Health Training Program
Penalty
Summary
The facility failed to ensure an effective behavioral health care and services training program was provided for employees for 12 out of 12 months reviewed, covering May 2025 through April 2026. The facility assessment, last reviewed on January 29, 2026, stated that the facility manages medical conditions and medication-related issues causing psychiatric symptoms and behaviors and identifies and implements interventions to support individuals with anxiety, cognitive impairment, depression, trauma, post-traumatic stress disorder, other psychiatric diagnoses, and intellectual or developmental disabilities. The assessment also indicated that, on average, 90 residents receive psychiatric services and 99 residents receive psychological services each month, and that staff education is a key component to assuring residents receive quality care. Despite those findings, the facility assessment did not identify or include a structured or ongoing staff training program specific to behavioral health care and services. A review of the facility's annual staff training modules for the review period did not show evidence that staff received training related to behavioral health care and services, including identifying behavioral symptoms, using non-pharmacological interventions, or responding appropriately to residents with psychiatric or psychological needs. During an interview on April 17, 2026, the DON and NHA were unable to provide documentation showing staff received behavioral health care and services training during the review period, and both confirmed the facility cared for residents with varying and complex behavioral health needs, including residents requiring psychiatric and psychological services.
Missing Behavioral Health Training for Five Staff Members
Penalty
Summary
Behavioral Health training was not provided for five of five staff members reviewed: NA Employee E4, NA Employee E5, RN Employee E6, LPN Employee E7, and NA Employee E8. Facility policy for the In-Service Training Program for nurse aides stated that all nurse aide personnel participate in regularly scheduled in-service training classes and that training attendance is entered on the employee's Record of In-Service. However, review of the personnel files for each of the five employees did not include credible annual in-service training on Behavioral Health for the period from 1/1/25 through 12/31/25. The personnel records showed that NA Employee E4 was hired on 3/20/24, NA Employee E5 on 10/22/19, RN Employee E6 on 5/30/19, LPN Employee E7 on 10/19/15, and NA Employee E8 on 3/9/81. During an interview on 4/16/26 at 2:15 p.m., the Nursing Home Administrator confirmed that the facility failed to provide training on Behavioral Health for these five staff members. The cited regulations were 28 Pa. Code: 201.14(a) Responsibility of licensee and 28 Pa. Code: 201.20(a)(d) Staff development.
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