Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for three out of four nurse aides, specifically NA Employee E10, NA Employee E11, and NA Employee E12. According to the Code of Federal Regulations S483.35(d)(7), the facility is required to conduct a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on these reviews. However, a review of the personnel records for these employees showed that the facility did not conduct the required annual performance evaluations based on their respective dates of hire. During an interview on January 10, 2025, the Nursing Home Administrator confirmed the facility's failure to complete these evaluations. This deficiency is in violation of the federal regulation and the Pennsylvania Code, which outlines the responsibility of the licensee and management requirements.
Plan Of Correction
The facility will complete annual performance evaluation for all those nurse aide staff employed at the facility for a year. This includes nurse aides E10, E11 and E12. The Administrator will re-educate the Director of Nursing and Human Resources that evaluations are a requirement annually for nurse aide staff. A master list of current nurse aide employees will be viewed weekly for six weeks to determine who qualifies for this annual performance review. The Director of Nursing or designee will complete these evaluations. The evaluation period for all employees will be June 2025.