Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance reviews for nursing staff were completed at least once every 12 months, as required by their policy. Specifically, the facility was unable to provide annual performance reviews for two Certified Nurse Aides. The facility's policy, revised in December 2014, mandates routine and periodic appraisals of job performance and competencies for each employee, with evaluations conducted annually. During interviews, the Director of Human Resources acknowledged that departments were responsible for completing these appraisals and that notifications and reminders were sent via email and during morning reports. However, they could not explain why the appraisals for the two Certified Nurse Aides were not completed. The Administrator noted that there were shortcomings in completing annual performance appraisals during 2023-2024 due to the human resource director position being a corporate shared role rather than a dedicated role for the facility.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the staff found to have been affected by the deficient practice is: The DON and/or designee will ensure that all nursing employees affected by the deficient practice receive an annual performance review for the period under review 2024. 2. How will you identify other staff as having the potential to be affected by the same deficient practice what corrective action will be taken? The DON and/or designee will ensure that all nursing employees receive an annual performance review for the period under review 2024. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? A list of all C.N.As on all shifts will be distributed via email to all nurse managers and nursing supervisors to ensure that all required nursing staff receive an annual performance review. All nursing supervisors will receive email notification to remind them that annual performance evaluations are due. The DON and/or designee will track and monitor compliance with completion of annual performance reviews for nursing staff. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur (i.e., what program will monitor the continued effectiveness of the systemic change)? A tracking list will be utilized to validate that all evaluations are completed and submitted to HR. The tracking will be audited weekly for one month, then monthly for three months. The results of the audits will be submitted to the Administrator and results of the audits will be reported to the QAPI committee monthly by the Director of Nursing for three months to the QAPI committee for action as appropriate.