Failure to Identify Missing CNA Annual Performance Reviews in QAPI Monitoring
Penalty
Summary
The facility failed to identify and address the lack of annual performance reviews for Certified Nursing Assistants (CNAs) within its Quality Assurance Performance Improvement (QAPI) Plan. The QAPI plan, last updated in 2017, required quarterly random personnel file reviews to ensure compliance with training, documentation, and regulatory requirements, with findings to be reported to the QA&A Committee. However, there was no documentation that these random audits of personnel files were performed, and the facility was unaware that annual performance reviews for CNAs were not being completed. As a result, 40 out of 69 CNAs employed by the facility did not have documented annual performance reviews, which was not identified or addressed through the facility's QAPI monitoring process.