Failure to Provide Yearly Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to provide evidence of yearly performance evaluations for three out of five nurse aides reviewed, specifically employees E20, E21, and E22. This deficiency was identified during a review of facility-provided documentation and interviews with staff. On December 18th, 2024, an email was sent to the facility's Director of Nursing, employee E1, requesting evidence of these evaluations. A follow-up verbal request was made later that day. Despite these requests, the facility was unable to provide the necessary documentation, a finding that was confirmed with the facility's administrator and Director of Nursing. This failure to conduct and document annual performance evaluations is a violation of the Pennsylvania Code 28 Pa Code 211.12(d)(1) and 28 Pa Code 211.12(d)(5) related to nursing services.
Plan Of Correction
Employees E20, E21 and E22 nurse aides have received their yearly performance evaluations. HR/DON/Designee to complete initial audit of nursing aides to ensure a yearly performance evaluation is completed. HR/Designee to re-educate nursing administration to ensure nurse aides receive a yearly performance evaluation. HR/Designee to complete monthly audits X 3 to ensure ongoing nurse aide yearly performance evaluations are completed. HR/Designee will report the findings of the audits to the QAPI Committee X 3 months.