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F0730
D

Failure to Conduct Annual Performance Evaluation for Nurse Aide

Pittsburgh, Pennsylvania Survey Completed on 02-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete annual performance evaluations for one of its nurse aides, identified as Employee E3, who was hired on October 11, 2004. This deficiency was discovered through a review of the facility's policy, personnel records, and staff interviews. The absence of a performance evaluation for Employee E3 was confirmed during an interview with the Nursing Home Administrator on February 14, 2025. This failure to conduct the required annual performance review is a violation of the regulatory requirement for regular in-service education and performance evaluations for nurse aides.

Plan Of Correction

A performance review was conducted with E3 by the Director of Nursing. Residents of the facility have the potential to be affected by this practice. The Human Resources Director will audit the Nurse Aide Employee files to ensure an annual performance review has been completed with Nurse Aides. Any Nurse Aide without an annual performance review will have one. A facility procedure regarding the annual performance review process was put into place 2/21/25. Director of Nursing and Human Resources Director received education from the Administrator, regarding the process of providing Nurse Aides Annual Performance Reviews. The Human Resources Director will review the schedule for each nurse's aides file that is due that month and corresponding documentation for (3) months to ensure compliance. 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.

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