Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that five randomly selected Certified Nurse Aides (CNAs) received the required 12 hours of annual in-service education. Specifically, CNAs #17, 18, 19, 20, and 21 only received 10 hours of training, which did not include mandatory topics such as abuse and residents' rights. This deficiency was identified during a recertification survey conducted from March 5 to March 12, 2025. The Director of Nursing confirmed the shortfall in training hours during an interview on March 11, 2025. The Administrator acknowledged the deficiency, attributing it to a lapse in monitoring due to turnover in the Assistant Director of Nursing position. The facility had two Assistant Directors of Nursing who did not remain employed, leading to a failure in ensuring the CNAs met the 12-hour in-service requirement. Both the Administrator and the Director of Nursing were aware of the deficiency by the end of the survey, recognizing that the CNAs had not completed the necessary training hours or covered the required topics.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 F730 P(NAME) Description: I. Immediate Corrective Action All C.N.A’s will be educated via in-service on resident abuse and resident rights. All 5 CNAs reviewed have been provided with additional in-services to equal the required 12 hours/annually. II. Identification of others A. All residents have the potential to be affected. The DNS/designee will review all CNA records to ensure that all CNA’s have received the mandatory in-services within the past year as well as 12 hours of in-service/year. Those found not to have these in-services will immediately be scheduled for in-services which will be provided by the DNS/designee. III. Systematic Changes The DNS/administrator reviewed the policy and procedure on C.N.A. yearly in-service and found it to be in compliance. IV. QA monitoring a. An audit tool was developed by the DON to ensure that all C.N.A’s are receiving the 12 hours of in-service annually specifically abuse and resident rights. b. Audits will be conducted weekly for 4 weeks on randomly selected CNAs and then monthly for 11 months. Any negative findings from the audits shall be reported to DON for immediate rectification. d. Audits shall be brought to QA meeting. V. Title Responsible a. Director of Nursing.