Failure to Document and Track Required CNA In-Service Training
Penalty
Summary
The facility failed to maintain documentation showing that five reviewed Certified Nursing Assistants (CNAs) completed the required 12 hours of annual in-service training, as mandated by facility policy and federal regulations. During interviews and record reviews, surveyors found that the facility did not keep individual records of completed training for CNAs, and the available documentation, such as sign-in sheets and quizzes, was incomplete, undated, or lacked necessary signatures. The spreadsheet provided by the Executive Director listed education topics and hours but did not align with the rolling 12-month period based on each CNA's hire date, making it impossible to verify compliance for the required timeframe. When asked, the Director of Nursing acknowledged that there was no system in place to monitor or track the completion of required training for each employee. The lack of proper documentation and tracking potentially affected all 71 residents in the facility, as there was no assurance that CNAs had received ongoing education in critical areas such as dementia care and abuse prevention. The deficiency was identified through a review of employee files and direct communication with facility leadership, who confirmed the absence of a reliable process to ensure and document annual training compliance.