Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nurse Aide (CNA) performance reviews were completed at least once every 12 months, as required by both facility policy and state regulation. During the recertification survey, it was found that five CNAs did not have documented performance reviews within the past year. The facility's policy, revised in April 2023, specifies that administrative, managerial, or supervisory staff are responsible for conducting annual performance appraisals and forwarding completion information to the human resources department, with each department maintaining the actual appraisal files. However, there was no evidence that these reviews had been completed for the identified CNAs, some of whom had been employed for several years. Interviews with facility leadership revealed a lack of compliance and awareness regarding the required frequency of performance appraisals. The DON acknowledged being behind on completing the appraisals, while the Director of Human Resources confirmed awareness of the annual requirement but admitted the reviews were not being completed on time. The Assistant Administrator was under the impression that appraisals were required every two years and was unaware that the annual requirement was not being met. This lack of adherence to policy and regulatory requirements resulted in the cited deficiency.