Missing Performance Evaluations in CNA Personnel Files
Penalty
Summary
The facility failed to maintain current, complete, and accurate personnel records by not including required performance evaluations for four of eight Certified Nursing Assistants (CNAs). During a review of employee records and interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON), it was confirmed that there was no documentation of current performance evaluations for these CNAs. The DSD, responsible for completing CNA evaluations, stated that the evaluations were not done and could not provide a reason, noting that the evaluations were due before her employment at the facility. The DON confirmed that performance evaluations are typically conducted after the probationary period and annually, and that these evaluations are essential for identifying staff training and education needs. A review of the facility's policies and procedures indicated that performance evaluations are required at the end of the 90-day probationary period, annually, and after promotions or transfers. The policies also specify that personnel files must include performance appraisals or evaluations. The absence of these evaluations in the personnel files for the identified CNAs was verified through record review and staff interviews, demonstrating noncompliance with both regulatory requirements and the facility's own policies.
Plan Of Correction
C4860-Employee Personnel Records A) IMMEDIATE CORRECTIVE ACTION: On 10/08/2025, DSD immediately completed performance evaluations for CNA 1, CNA 2, CNA 3, and CNA 4. B) HOW FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE: On 10/8/2025, DSD and Assistant DSD reviewed all current CNA files to ensure the presence of an evaluation within the last 12 months. C) MEASURES PUT IN PLACE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT OCCUR: Effective 10/30/2025, DSD will review all CNA anniversary dates monthly to ensure annual evaluations are completed timely and as per facility protocol. D) HOW THE FACILITY PLANS TO MONITOR ITS PERFORMANCE TO MAKE SURE THAT SOLUTIONS ARE SUSTAINED: The DSD/Designee will present monthly evaluation completion reports to the QAPI/QAA committee monthly. These audits will be reviewed for the next three months to ensure compliance. E) COMPLETION DATE: 10/31/2025 C4905-Employee Personnel Records