Failure to Conduct Timely CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) performance reviews were conducted at least once every 12 months, as required. Specifically, three CNAs, hired in 2017, 2018, and 2020, did not have documented performance reviews within the last 12 months. During interviews, the Human Resource Director acknowledged that unit supervisors were responsible for completing these reviews and that they should be filed in employee folders. However, the director was unaware that the reviews for these CNAs had not been completed. The Assistant Administrator was also unsure why the reviews were not conducted, and the Assistant Director of Nursing, who had previously assisted with these reviews, believed they had been completed. This deficiency was identified during a recertification survey conducted from February 10 to February 14, 2025.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 F730 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: - The performance reviews for Certified nurse aide #2, #3, #4 were completed on 2/17/25. The human resource director audited all current Certified nursing assistants to ensure performance reviews in place. No additional occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Director of nursing and administrator reviewed staff performance review policy with no revisions needed. - The Director of human resources was educated on criteria that performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews. - The director of Human Resources/ designee will audit every 2 weeks for employees eligible for performance reviews to ensure they are completed per specifications x 1 month, then monthly x 3 months. - The director of Human Resources/ designee will keep a running log of all certified nursing assistants eligible for performance review and ensure they are filed in employee folders once completed. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. - The Director of Human Resources/ designee will audit every 2 weeks for employees eligible for performance reviews to ensure they are completed per specifications x 1 month, then monthly x 3 months. - Any discrepancies will be reported to administrator and immediately corrected. - The results of the Audit will be reported at monthly QAPI.