Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to conduct annual performance evaluations for its nursing staff, specifically for five nurse aides identified as Employees E11, E12, E13, E14, and E15. This deficiency was discovered through a review of personnel records and confirmed during an interview with the Nursing Home Administrator. The evaluations were not completed based on the date of hire, as required by the regulations, which stipulate that a performance review must be conducted at least once every 12 months for each nurse aide. This oversight indicates a lapse in adhering to the mandated staff development protocols.
Plan Of Correction
As a newly established company, we acknowledge this deficiency and view it as an opportunity to build a comprehensive and sustainable performance management system from the ground up. Recognizing the importance of staff development and regulatory compliance, we are committed to thoroughly evaluating all existing personnel and creating a robust framework for performance evaluations that supports both accountability and professional growth. To allow for a thoughtful and fair assessment of our current workforce, we have established a corrective action date of June 17, 2025. This extended timeline provides the necessary window to evaluate all nursing personnel, review existing training and evaluation protocols, and implement a standardized annual review system that aligns with each employee's hire date. During this period, Human Resources will work closely with the Director of Nursing and department heads to build a tracking system that ensures timely evaluations moving forward. A performance evaluation template based on job-specific competencies and core values will be finalized and implemented by the corrective date. All nurse aide personnel files will be audited and updated, and a schedule will be created to complete all outstanding evaluations by June 17. Training for supervisors on conducting effective and compliant evaluations will also be completed prior to that date. Addendum to Ensure Compliance with 60-Day Requirement: The facility is committed to completing all outstanding performance evaluations for current nurse aide personnel by the regulatory deadline of June 17, 2025. Human Resources, in collaboration with the Director of Nursing, has begun auditing personnel files and will implement a tracking system by May 31 to support timely completion. A standardized evaluation template will be finalized, and supervisors will receive in-service training to ensure evaluations are conducted appropriately. While every effort will be made to meet the June 17 target, if additional time is needed to ensure thorough and meaningful evaluations, the facility will continue working diligently to complete all evaluations as soon as possible. A long-term evaluation schedule based on hire dates will be implemented beginning July 1, 2025, to support ongoing compliance.