Deficiency in Nurse Aide In-Service Training Hours
Penalty
Summary
The facility failed to ensure that certified nurse aides received the required 12 hours of annual in-service training, as mandated by their corporate policy. Specifically, three out of five reviewed Certified Nurse Aides did not complete the necessary training hours. Certified Nurse Aide #18 completed only 6.0 hours, Certified Nurse Aide #20 completed 6.5 hours, and Certified Nurse Aide #21 completed 9 hours of training. This deficiency was identified during a recertification survey conducted from January 22 to January 30, 2025. The Nurse Educator and the Administrator both acknowledged the shortfall in training hours. The Nurse Educator cited technical difficulties that prevented the completion of in-services at nurse stations, while the Administrator mentioned challenges related to staff time and technical issues. The online in-service program was removed from unit computers due to these technical issues, requiring staff to use facility classroom computers, which was difficult due to their workload and inability to leave their units during shifts.
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 residents found to have been affected by the deficient practice is: There were no residents affected by this deficient practice. To correct the deficient practice, the Nurse Educator and/or designee will provide educational sessions twice weekly for certified nurse aides to meet the required twelve hours of mandatory annual in-service training. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above)? All residents have the potential to be affected by the deficient practice. The Nurse Educator and/or designee will generate a list of all certified nurse aides to track the staff required to receive the mandatory training and schedule employees. An audit of all current CNAs will be conducted to identify any staff who has not completed their 12 hours of annual in-service. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? Training will be scheduled weekly, with one hour allotted for each training, and all attendance will be tracked and trended. The Nurse Educator will address any issues with non-compliance with the DON and/or designee to ensure continuing competence of nurse aides' mandatory requirement of twelve hours of training. 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)? The Director of Nursing and/or Designee will report the results of staff mandatory training to the QAPI Committee monthly by the Director of Nursing/Designee for 3 months to the QAPI committee for action as appropriate.