Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) performance appraisals were completed at least once every 12 months, as required by their policy. Specifically, the personnel records for two CNAs, hired on 7/1/2022 and 6/20/2017 respectively, lacked documented evidence of annual performance evaluations. CNA #2 had no performance evaluation since their hire date, and CNA #3 had not received an evaluation since 9/5/2018. This deficiency was identified during an abbreviated survey (NY00362050) through record reviews and interviews. Interviews with the Director of Nursing and the Director of Human Resources revealed that the responsibility for conducting these evaluations lies with the nursing department, while Human Resources reviews and notifies the nursing department if evaluations are not completed. The Director of Nursing, who had been in the facility for two months, admitted to not having completed any performance evaluations. The Director of Human Resources confirmed the absence of recent evaluations for the two CNAs, acknowledging that the evaluations were not completed according to the facility's policy.
Plan Of Correction
Plan of Correction: Approved December 27, 2024 Certified Nurse Aide #2 yearly performance review was conducted on 12-20-24. Certified Nurse Aide #3 yearly performance review was conducted on 12-20-24. The facility conducted an audit of all employees’ files. Director Human Resources/Designee and department manager will ensure all identified employees with outstanding yearly evaluation be completed by 1/8/25. Policy and Procedure was reviewed on 12/19/24 for yearly evaluations. No revisions made. Director of Human Resources, Department Heads and Managers were educated on 12/20/24 on the importance of conducting employee yearly evaluation. The Director of Human Resources/Designee will conduct weekly audits and to track and meet with all employees who are due for yearly evaluations. Director of Human Resources/Designee will meet with department manager and employee to complete evaluation in accordance with the facility policy and procedure. Director of Human Resources will conduct weekly audit x3 months, then monthly x3 months. The audit results will be submitted to the monthly QAPI committee for review. The Responsible Party: Director of Human Resources.