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P1440

Missing Job Descriptions in Employee Personnel Files

Lake Ariel, Pennsylvania Survey Completed on 08-15-2025

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 personnel records for three employees, specifically a nurse aide, an activities aide, and a dietary aide, contained documented evidence of their job descriptions. Review of the personnel files for these employees, all hired in 2025, revealed that none included a written job description outlining the duties, responsibilities, and qualifications for their respective roles. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the facility could not produce the required documentation for these employees.

Plan Of Correction

Employee #5, #7, and #8 have signed job descriptions. To identify like individuals that have the potential to be affected, NHA/designee will audit new hires in the last 14 days to ensure job descriptions are signed by the employee. To prevent this from recurring, Human Resources will be educated by NHA/designee on personnel policies and procedures. To monitor and maintain ongoing compliance, NHA/designee will audit new personnel files weekly for the first four weeks, then monthly for two months, to ensure personnel files contain the signed job description. Results will be reported to QAPI for recommendations and follow-up.

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