Deficiency in Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to meet the required in-service training standards for nurse aides, as mandated by §483.95(g). Specifically, the facility did not ensure that four nurse aides received at least 12 hours of in-service education within 12 months of their hire date anniversary. This deficiency was identified through a review of facility policy, personnel in-service training records, and staff interviews. The facility's policy, last reviewed on 10/20/24, stated that an effective training program would be developed and maintained for all staff, but this was not adhered to. The review of training records revealed that Nurse Aide Employee E1, hired on 10/9/22, had no documented evidence of education between 10/9/23 and 10/9/24. Similarly, Nurse Aide Employee E3, hired on 10/11/04, had no documentation of completed education from 10/11/23 to 10/11/24. Nurse Aide Employee E4, hired on 10/11/05, and Nurse Aide Employee E5, hired on 11/12/13, both had education files with a "12-hour in-service packet," but no dates confirmed that the education occurred within the required timeframe. The Nursing Home Administrator confirmed the facility's failure to conduct the necessary in-service education during an interview on 2/14/25.
Plan Of Correction
No residents were affected by this deficiency. All residents have the potential to be affected by this deficiency. VP of Clinical Services provided education to the Administrator, Director of Nursing, and Human Resources Director regarding the need to track 12 hours of annual training for certified nursing assistants. The facility has developed a tracking form to track these education hours for each nurse's aide. The Human Resources Director will complete a monthly audit on all employees due to complete their 12 hours of training that month to ensure they have received the required 12 hours of training. 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.