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F0729
D

Lapsed CNA Certification Leads to Deficiency

Rochester, New York Survey Completed on 01-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the certification of a Certified Nursing Assistant (CNA) was current during their employment. Specifically, the CNA's certification had lapsed and was not renewed, yet the CNA continued to work in the facility providing direct resident care. The facility's policy required the Director of Nursing to monitor CNA recertifications monthly and initiate the renewal process at the beginning of the month in which the certificate was due to expire. However, the CNA's certification expired, and the renewal process was not completed in a timely manner, resulting in the CNA working without a valid certification. Interviews revealed that the Business Office Manager and the Director of Nursing were responsible for ensuring certifications were up to date. The Business Office Manager stated that there was a perceived grace period of 90 days during which CNAs could work while their certification was being processed, although this was not officially confirmed by Prometric. The delay in processing the renewal was attributed to an error in the employer code and missing information on the renewal form. Despite these issues, the facility allowed the CNA to continue working, which was a violation of the requirement to have a valid certification for direct resident care.

Plan Of Correction

Plan of Correction: Approved February 7, 2025 1. CNA #4 was terminated from the facility effective 10/15/2024. 2. An audit of all CNAs certification at the facility was completed and reviewed. There were no other CNAs that did not have an active C.N.A certificate. Completed: 1/2/2025 3. The facility has reviewed the facility policy on C.N.A renewal and there has been no changes. A spreadsheet is sent to this Director of Nursing and the Administrator that automatically populates notification 45 days prior to the expiration date. 4. All renewed C.N.As will be reported to the Quality assurance team for 3 months then quarterly thereafter to ensure that all Certification renewals are completed timely. Responsible party: Business office

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