Deficiency in CNA Performance Reviews and In-Service Education
Penalty
Summary
The facility failed to ensure that a performance review of every nurse aide was completed at least once every 12 months, and that each nurse aide received no less than twelve hours of in-service education per year based on the outcome of these reviews. This deficiency was identified during a survey, which included staff interviews and a review of facility documentation. Specifically, the facility did not conduct timely performance reviews for two Certified Nursing Assistants (CNAs), nor did it provide the required in-service education hours. Certified Nursing Assistant #1 had not received a performance evaluation since May 4th, 2021, and had attended only nine in-services, which did not meet the required twelve hours of education. Additionally, Certified Nursing Assistant #4 had only one performance review on file dated July 6th, 2017, and had attended only three in-services since their hire date. The documentation revealed that Certified Nursing Assistant #1 had a history of verbal counseling in 2024 for issues such as failure to document and improper break time. Certified Nursing Assistant #4 had received warning notices for various infractions, including leaving a resident unattended in a bathroom. Despite these documented issues, the facility did not ensure that these CNAs received the necessary performance evaluations and in-service education to address and improve their job performance. This lack of compliance with regulatory requirements for performance reviews and education contributed to the identified deficiency.
Plan Of Correction
Plan of Correction: Approved December 23, 2024 The three staff members have been terminated based on the findings of the investigation. The facility will audit all current CNAs 12 hours of education and annual performance evaluations. Any CNAs not in compliance with the 12 hours of education or annual performance evaluation will be corrected. Education will be provided to the Director of Human Resources and all CNA staff that 12-hour education is required each year as well as annual performance evaluations. The facility will audit all CNAs 12 hours of education and annual performance evaluations weekly for 3 months, then monthly thereafter to ensure all 12 hours of education and annual performance reviews are in compliance. Any findings of noncompliance will be reported to QAPI. Responsibility: Director of Nursing and Director of Human Resources or Designee