Deficiency in Nurse Aide Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for nurse aides, as required by federal regulations. Specifically, the facility did not provide the mandated annual in-service training on Quality Assurance and Performance Improvement (QAPI), Communication, and Compliance and Ethics for three nurse aides, identified as Employees E3, E14, and E15. This deficiency was identified through a review of personnel records and in-service documentation, which revealed the absence of the required training sessions. The Director of Nursing confirmed during an interview that the facility did not meet the training requirements for these employees. The nurse aides in question were hired on various dates, with Employee E3 hired in September 2020, Employee E14 in October 2014, and Employee E15 in August 2020. The lack of compliance with the training requirements was noted as a deficiency under the relevant Pennsylvania Code sections, which pertain to management, staff development, resident rights, and personnel policies and procedures.
Plan Of Correction
Annual in-service education to include QAPI, communication, and ethics to be provided to employees E3, E14, and E15 by the Director of Nursing (DON)/designee. The DON/Designee will provide education on QAPI, communication, and ethics to all current nurse aides. The facility staff educator and human resources director will be educated by the Administrator/Designee on the required annual in-service requirements for nursing assistants. The Administrator/Designee will randomly audit 2 nursing assistant employee files monthly x 3 months to ensure completion of the required annual education. Findings from the audits will be presented at QAPI quarterly meetings for review and recommendations.